TAP CHi Y DU'O'C L A M SANG 10
Nhan 4 trircmg hop u hau nhan va nen so xam lan 6 mat dirg^c phau thuat bang duong mo phu-c hop so - 6 mat - go ma
The Resection of Orbital Tumors and Intraorbital Invaded Skull-base Tumors using the Cranio-orbital-Zygomatic Approach: A Review of the four Cases.
Pham Ngoc Minh, Nguyin Trong Yen, Benh vien Trung uang Qudn dpi 108 Vu Ngoc Lam, NguyenThanh Tuan, Pham Hda Binh
Tom tat:
U hau nhan cau va cac khdi u vung nen sp phat trien xam lan vao bdc mdt tuong ddi hiem gap.
Chung tdi bdo cao kinh nghiem vdi dUdng md phUc hop sp - d mat - go ma trong phau thuat u vung hau nhan va nen so trude. 8dn benh nhan vdi cdc tdn thuang khac nhau da 6uac phau thuat vdi ket qud tdt.
Ddy Id dudng mo an todn va cd hieu qud.
TUkhda:^} hau nhan, u nen so trudc
Summary:
The orbital tumors and intraorbital invaded skull-based tumors are rare. We report our experiences with the cranio-orbital-zygomatic approach. This technique is suitable to lesions situated in the region orbital tumors and intraorbital invaded skull-based tumors. Four patients suffering from different lesions were operated with good postoperative and cosmetic results. We conclude that this approach is safe and useful in selected cases.
Keywords: The orbital tumors,intraorbital invaded skull-based tumors
l . O a t v a n d e ap d u n g la dUdng m d n i p sp vung trdn [1]. Tuy nhien, dUdng md nay cd m d t sd ban ehe nhU: pham Phau thudt cdt bd triet de cdc khdi u hau nhdn vi phdu t r u d n g hep, ton t h u a n g do ven nao nhieu.
cdu va cdc khdi u vung nen sp phat trien vao hdc ^^^^ ^^^^^ ^^ [3l i^^uyel hong tran d mdt ddi hdi mdt^ la mdt khd khan thach thUe ddi vdi cae phau p^^j ^^^ ^^^ ^ ^ ^ ^ g ^ ^ q^3 ph^^c hop so-tran d mdt- thudt vien, Nhieu dUdng mo khde nhau dd dUdc sU gd ma da phan nao khde phuc nhUng han che nay.
dung. Muc dich eua tat cd d u d n g m d la tiep can tdn ^ ^ - ^ Q^ ^^^^^g j^^p ^ ^^^ ^han vd u nen so xam lan thuang mdt cdch gan nhat, gidm nguy ca t d n ^ . ^ ^^^ ^ ^ ^ ^ ^ ^ ^ p^^^^ ^hudt tai Benh vien Trung thuong do ven ndo t r o n g khi van dam bdo bdc Id ^^^^ Q ^ ^ ^ ^ ^ i 1Q8_ ^^ ^^^ ^^^ g i ^ ^ j ^^uyen khoa dupe tdi da tdn thUdng. D u d n g m d kinh dien dupe ^^^^^ - ^ , ^ 1 ^ ^^^^ ^^ Ham mdt-Tao hinh, chung tdi m u d n de ddnh gia hieu qud dUdng md nay bdng I'lian bifn khoa hgc: PGS TS NGUYEN TAI SON viec phdn tich nhUng Uu diem va han che cua nd.
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY
2 , Ooi t u o n g va p h u o n g p h a p nghien cufu 2.1. Doi tuong
• Gom 04 benh nhan 6uac chan doan u hau nhan va u nen sp co xam lan vao hoc mat dLfgc p h l u thuat bang ducjng mo phufc hop sp - tran 6 mat - go ma tai Benh vien Trung uong Quan doi 108,
. Thdi gian m o : tL( 2010 den 2013
• Chan d o a n xac d i n h di/a tren viec phan tich cac p h i m cat Idp vi t i n h (CLVT) va c p n g hifcing tif (CHT) trudc m o .
TT 1 2 3 4
Ho ten Nguyen Tuan Ch Nguyen DUc Ph Hoang Thj K.
Lai Van L
Tuoi 32 29 46 36
Gidi NAM NAM NCr NAM
Chan dodn U hdu nhan U hdu nhdn U bau nhdn U mang ndo xoang hang
xam lan hdc mat
MUe dp PT Lay toan bd u Lay todn bd u Lay toan bd u Lay u khong todn bd
2.2. Phuang phap nghien cijfu Phan tich hoi cUu.
2.3. Quy trinh phiu thuat
D u p c t h u c hien theo m d t d cilia Al-Mefty [3].
2.3.1. Td the benh nhdn
Benh nhdn duac nam ngUa, dau eua benh nhdn 6dac nang cao khoang 20 dp vd xoay khodng 20-30 dp sang phia ben ddi dien, Cd d i n h dau bang khung Mayfield.
2.3.2. Dudng rach da, bdc 16 dien md xuang D u d n g rach da coronal 6dac bat dau l e m trudc g d binh tai ngang mUc c u n g xUdng g d md va keo dai theo chdn tde len den phia trudc dudng thai dUdng ddi ben. Phau tich qua Idp can galea tranh lam t o n t h u a n g m d n g x u o n g sp. Vat da dau dupclat len can t h a n bao t d n d p n g mach thai dUPng nong va Idp can sau.
i;-"<^
^^M^
Hinh 1. Tuthe, Hudng rach da [3]
TAP CHi Y DU'O'C LAM S A N G 108 Tgp 9 - S o 2/2014
• Bdc tach can so t d i da len phia tren bdc Id ddy than kinh tren 6. Cdn thdi d u a n g duac phau tich khdi eung xuang gd md theo phia dudi mdng xuong. Co thai dUdng dUdc rach dpe len tren theo dudng dl cua dpng mach thdi dUPng ndng vd dupe tach dudi mang xUdng tU hd thdi dUdng, bdo t d n ddng mach thai duong sau vd than kinh ehi phdi Id nhdnh 3 eua than kinh sinh ba.
2.3.3. Md xuang
• D u d n g cat xuang t h d nhat bat dau tU diem mdc gidi phau nam d v u n g Idm ngay sau d u d n g tiep gidp giUa xUPng tran va xUdng gd ma, dpc theo sdn hd sp giUa ngay phia tren cua than xUong g d ma vd dpc theo b d ngodi xUPng thdi dUPng, ket thuc d tran d mat.
• Dudng cdt xuong t h d hai dupc thiet ke doc phia ngodi eua sdn hd giUa tdi xupng cdnh budm.
• D u d n g cdt tiep theo dpc tren d mdt t d i vung Id khoan ban dau den vung m d xUdng dpe theo b d tren d mdt, can than tranh lam rach mang xUPng hoac mang cdng. Manh xUong bao g d m thdnh ngodi vd thdnh tren d mat duac lay ra nguyen khdi.
the 6\Sac neo lai trong qud trinh phuc hinh. Sau d d xUPng gd md dupe g d xudng dUdi cung vdi co can.
2.3.4. Dong vet mo
• TrongtrUdng hpp ed m d mdng eUng, mdng cUng can duac d d n g kin bang mdnh ghep cdn sp hoac can d u i t u t h d n d e g i d m dp luecho ndo.
• Thanh o mat, xUPng g d ma cd d i n h bdng nep vit.
3. Ket qua
Trong 4 trUdng hpp: 03 trUdng hpp dupe lay toan bd t o n t h u o n g , 01 t r u d n g hpp u tdi phdt xam lan vdo hdc mat can sd d u n g dUdng m d phUc h p p sp-d mat-go ma de tiep can phan u xam lan d mat.
Khdng cd bien chUng nao xay ra trong qud trinh theo d d i xa. Cde benh nhan deu ed trieu ehUng cdi thien t d t sau m d . Vdi viec sU d u n g dUdng m d phUc hop sp-6 mat {eho 03 trudng hop) hoac so-d mat-go md (eho 01 trudng hop) da eho phep tao phau trudng rdng rai de lay u, cam mdu. Ton t h u o n g ddac lay t i mi dUdi kinh hien vi, ket qua sau m d dddc xdc dinh bang CLVT vd CHT. Seo m d nam trong vung ed tdc vdi ket qua ve tham my chap nhdn dupe.
B I N H A N M I N H H O A TrUcfng hdp thCfnhat
- Benh nhdn Nguyen DUc Ph, 29 tudi, nam - Vao vien vdi bieu hien ldi, gidm thj lUc mdt trdi.
Tren CLVT va CHT xdc dinh: U hdu nhdn cau ben trai, kich thudc 3x4em.
- D u d n g m d : d u d n g m d t r a n - t r a n d mdt.
- Ket qud: lay todn bp u
- Sau m d , mat het ldi, thi luc cdi thien rd. Khdng ed bien chUng xa
Hinh 2. Dudng mdxuang [3].
Trong edc trudng h o p khoi u ndm phia ben cua hau nhan tien hdnh cdt xuang g d ma. Xuang gd ma dUde cdt cheo theo hudng cheeh tren ra ngoai tdi
da. Dudng cdt thiet ke cheo sao cho cung g d ma cd Hinh 3. Uhdu nhdn (A,B: trudc mo; C: sau mo).
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol9-N'^2/20I4
TrUdng hap thtjfhai Benh nhan Lai Vdn L, 36 t u d i , nam
- Benh nhdn dd dupe m o u m a n g ndo hd thdi d u o n g ben trai bang dUdng m d kinh dien, trUde do 03 nam. Dd m d lay gan toan bd u, de lai phan u bam vao xoang t i n h mach hang.
Benh nhdn vao vien vdi bieu hien dau nhUc, ldi, giam thj luc mat trai.Tren CLVT va CHT phdt hien u tai phdt, phat t h e n vdo hoc mat trai. U phan Idn bj d d n g vdi. Kich thUde Idn 5x6cm.
- D u d n g m d : d u d n g m d t r a n - t r a n o m a t - x u a n g g d ma t a n g tdi da khd ndng tiep can t d n t h u a n g v u n g hoc m a t Sau mo dupc dieu trj xa^phdu ket hpp cho phan u cdn lai v u n g xoang hang.
- Sau mo: thi lUc cai thien tdt, mat het ldi
timh 4, u mang nao (A, B: trUdc mo; C sau mo) 4. Ban luan
U hdu nhdn Id hiem gdp va vi tri t d n t h u a n g t h u d n g sdu va khd can thiep do phau t r u d n g han che [1]. McArthur va sau d d la Frazier la nhUng ngUdi dau tien ket h p p ky t h u d t m d m d so vdi tran d mat vdi de tiep can cde t d n thUPng v u n g thap cua xupng tran vd v u n g yen [1]. Ndm 1969, Yasargil da gidi thieu d u d n g md qua vung thdi d u o n g . Tuy nhien d u d n g m d ndy chUa ddp Ung yeu cau lam rdng phdu t r u d n g nen nguy ca lam t d n thUdng ndo Idn do phai ven ndo. Jane vd cdng sU sU d u n g p h u o n g phap m d tran d mat de loai bd cae u vung hoe mat [7]. DUa tren nhdng d u d n g mo tren, Al Mefty da edi tien, ket h p p edc d u d n g m d thanh d u d n g m d xuong trdn - d m d t - m d [ 4 ] , [ 6 ] , [ 9 ] .
Bdng viec sU d u n g d u d n g m d cua Al Mefty tren 4 benh nhan vdi khdi u v u n g hdu nhan, chung tdi nhan thay d u d n g m d ndy ed nhUng Uu diem sau:
- D u d n g m d sp - d mdt - g d md bdc Id dddc dien quan sat kha rdng, t d trudc ra sau den tan 16 t h j giac, viec nhae khdi phUe h d p xUdng nay ra g i u p phau
t h u a t vien ed t h e t i e p can t d n t h U d n g m d t each tri/c tiep, rdng rdi vdo t r o n g t d i tan m d n h sang vd ra ngoai tdi tdn t h d n h ben eua d mat. Chinh vi tao ra dupe phau trUdng d u rpng cho p h e p quan sdt toan dien, trUc t i e p t d n t h u a n g , nen d u d n g m d nay con cd tdc d u n g lam gidm dUdc ede t d n t h u a n g do dpng tde ven ndo gay ra.
- D u d n g m o s p - 6 m a t - g d ma la dUdng md rat linh boat, cd t h e thay ddi t u y tren tUng benh nhan cu the. Vdi 03 trUdng h o p t d n thUdng chi khu tru t r o n g o mat, ehi can m d xUdng trdn va tran 6 mdt la d u . NhUng vdi 01 trUdng h p p eon lai d o tdn thuong cd ca 6 h d sp giUa hay t h d n h ngoai d mdt nen da phdi m d rdng phdu t h u d n g bdng each cdt xuang go md. Theo nhieu tac gia day chinh Id uu diem tdn nhat eua d u d n g m d nay t r o n g viec can thiep eac ton thUdng nen sp xdm lan d m a t [4], [6].
- Cd 04 b e n h nhan deu dUPe bdo tdn dUOc x u a n g tran 6 mat, khac vdi t r o n g d u d n g md md nap so v u n g trdn kinh dien t h u d n g gay khuyet tran 6 mat, ddi khi gay t h o d t vi nao, ddi hdi phdi phuc hinh ehe p h u . Mat khac viec phuc h i n h trdn 6 mat nhieu khi rat khd khan, d d n g t h d i phai d u n g cac vat lieu nhan tao cd t h e gay viem rd keo dai [7].
Tuy nhien, c u n g can nhan m a n h m d t sd han che khi sU d u n g d u d n g m o phUe h o p n a y d d la:
- DUdng m d dai, ky t h u d t bde tdeh phUe tap hon so vdi d u d n g m d kinh dien.
- Dien bdc tach p h d n m e m khd Idn. Tuy nguon cap mdu cho v u n g m o rat p h o n g phu nhUng viec d o t dien cam mdu hay gap vat da lau cd th^ 3nh h u d n g den c u n g cap mau va cdc bien ehUng khac eua vat da. Viee d u n g d o t dien n d n g dpc tren can thai d u o n g va qua t r i n h bde tdch co nay cd the gay t d n t h u o n g cho nhdnh t r d n x u a day than kinh mat vd nhdnh eua ddy t h a n kinh sinh ba gay teo cdthai dUPng sau m d [8,10]. M p t sd tac gid khuyen cao bao t o n d d n g mach thai dUdng n d n g khdng chi bdi tac d u n g eua nd nhU v d n g noi mach sau nay ma con SLI d u n g n h u n g u d n mach nudi cua c d thdi duang [8].
- Ca 04 trudng h o p deu cd t o n t h u a n g xoang tr^n, Chung tdi dd xU tri bdng each lay b d niem mac xoang vd lap day cdc d n g m u i tran bdng ca vd can so de ngan cdch giUa mang eUng vd xoang hd. Dieu nay eung phi) 52
TAP CHl Y Dl/QC LAM S A N G 108 Tgp 9 - S o 2/2014
hop vcri ban luan cCia m p t sd tac gid cho rdng vung m d xUong ed t h ^ gay ton t h u o n g xoang tran vd xoang ham tren la ngudn tiem tang eua cdc bien ehUng nhu nhiem trung, tran khi xoang so [1,3].
- Viee bdc tdeh mang eUng khdi nen sp ed the gay ra cac bien chUng nhU rach mdng ndo rd dich nao tuy, bdc tdch nhdnh eua than kinh sinh ba cd the gay dau, di edm nUa mat hoac yeu co nhai sau mo. Chung tdi khdng gap bien chdng nay cd t h e do viee sd d u n g kinh hien vi phau t h u d t dd giup tdng tdi da khd ndng quan sdt vd thao tac lam giam tdi da edc bien ehUng nay.
5. Ket luan
D u d n g mo sp - 6 mat • g d md Id dUdng m d ed the cho phep tiep can m d t each gan nhat, bdc Id tdi da cde tdn thUPng vung hdu nhan hoac cac t d n thUPng nen sp xam lan vdo hdc mat. DUdng m d nay gidm dupc nguy ca t d n t h u a n g nao do ven ndo, bdo tdn dupe xuong tran tren hoe mat khdng phdi tdi tao sau khi lay u. Tuy nhien d u d n g mo nay ed mdt sd nhupe diem: d u d n g rach da ddi, dien bde tdeh phan mem Idn, t h u d n g pham vao cdc xoang n h u xoang trdn, xoang ham tren nen cd nguy co gay viem nhiem sau m d . Can cd nhUng nghien cdu sau hon de edi tien dudng m d , han che nbUng nhupe diem cua dudng mo nay t r o n g t u a n g lai.
Tat Ii0u tham khao
1 Alaywan M, Sindou M, (1990), Fronto-temporal approach with orbito-zygomatic removal surgical anatomy. Acata Neurochir 104:79-83.
2. Al-Mefty O, (1987), Supraorbital pterional approach to skull base lesions. Neuro-surgery 2 1 : 474-477.
3. Al-Mefty O, Anand VK (1990), Zygomatic approach to skull-base lesions. J Neurosurg 73:688-673.
4. Al-Mefty O, Fox JL (1985), Supralateral orbital exposure and reconstruction. Surg Neurol 23:609-613.
5. Fujitsu K, Kuwarabara T (1985), Zygomatic approach for lesions in the interpe-duncular cistern. J Neurosurg 62: 340-343.
6. Hakuba A, Liu S, Nishimura S (19861 The orbitozygomatic infratemporal approach. A new surgical technique. Surg Neurol 26:271-276.
7. Jane JA, Park TS, Pobereskin LH, et al. (1982), The supraorbital approach. Technical note.
Neurosurgery 11: 537-542.
8. Kadri P, Al-Mefty O (2004), The anatomic basis for surgical preservation of the temporal muscle. J Neurosurg 100:517-522.
9. Pellerin P, Lesion F, Dhellemmes P, et al. (1984), Usefulness of the orbitofrontoma-lar approach associated with bone reconstruction for frontotemporosphenoid meningioma.
Neurosurgery 15:715-718.
10. Sekhar LN, Schramm VL Jr, Jones NF (1987), Subtemporal-presuricular infratermporal fossa approach to large lateral and posterior cranial base neoplasms. J Neurosurg 67:488-499.
