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本期为Worldneurosurgery定期连载的河南省人民医院张长远医师终审的《动脉瘤大师级神作--Seven Aneurysms》著作第九期。本期主要内容为 术中破裂，《Seven Aneurysms 》系列内容包括 Section I The Tenets：1. 在显微镜下操作；2. 蛛网膜下腔的解剖；3.脑牵拉；4.血管控制；5.临时夹闭；6.永久夹闭；7.夹闭后的检查；8.必要的脑切除；9.术中破裂。Section II The Approaches: 10.翼点入路; 11.眶颧入路; 12.前纵裂入路; 13.远外侧入路。Section IIIThe Seven Aneurysms: 14.后交通动脉瘤; 15.大脑中动脉瘤; 16.前交通动脉瘤; 17.眼动脉动脉瘤; 18.胼周动脉瘤; 19.基底动脉分叉动脉瘤; 20.小脑后下动脉动脉瘤。 【Seven Aneurysms】往期回顾
第九期： Intraoperative Rupture---术中破裂 ■Ever-Present Danger---时刻存在的危险 Uncontrolled intraoperative bleeding is one of the most feared complications in neurosurgery. It has been said that uncontrolled bleeding is the one factor above all others that unnerves surgeons. As a corollary, surgeons who are agile in handling vascular structures and controlling bleeding can deal with most crises that arise in a neurosurgical procedure. Therefore, managing catastrophic bleeding is an invaluable skill, no matter one’s subspecialty or practice. 无法控制的术中出血是神经外科最可怕的并发症之一。一直以来的说法是，无法控制的出血最令外科医生望而生畏，超过任何其它因素。由此可推，能够敏捷处理血管结构和控制出血的外科医生就能够应付神经外科手术中出现的绝大多数危险场面。因此，无论是什么亚专业，对灾难性出血的处理都是我们的一项宝贵的技能。
Intraoperative rupture is an ever-present, unavoidable danger in aneurysm surgery. It occurs in 5 to 10% of aneurysm cases, mostly with fragile, previously ruptured aneurysms in patients with subarachnoid hemorrhage (SAH). It does not diminish with increasing surgical experience of the neurosurgeon performing the operation. However, the timing of intraoperative aneurysmal rupture may well reflect the neurosurgeon’s experience. Ruptures occurring during the initial exposure, or predissection, are more frequent early in one’s experience, typically due to brain retraction with adherent aneurysms such as superiorly projecting ophthalmic artery (OphA) aneurysms stuck to the frontal lobe, inferiorly projecting anterior communicating artery (ACoA) aneurysms stuck to the optic chiasm, or posterior communicating artery (PCoA) aneurysms stuck to the temporal lobe. Avoiding retraction or using it sparingly eliminates these mistakes. Similarly, rupture during clip application becomes less frequent with experience, reflecting the developing sense for when an aneurysm is ready to be clipped. Inadequate dissection of the aneurysm’s neck and poor clip application are responsible for ruptures during clipping that occur in procedures performed by inexperienced neurosurgeons, reflecting a natural fear of intraoperative rupture. The seasoned neurosurgeon is more likely to aggressively manipulate the aneurysm and precipitate rupture during the final dissection maneuvers, preferring an expected rupture of a fully prepared aneurysm over an unexpected rupture during clip application of an underprepared aneurysm. 对于动脉瘤手术，术中破裂是一个始终存在的、不可避免的风险。在动脉瘤病人，其发生率为5%-10%，多发生在脆弱的、曾有破裂的动脉瘤性蛛网膜下腔出血(SAH) 病人。神经外科医生手术经验的增加并不会减少术中破裂的发生。然而，术中动脉瘤破裂的时机很能反映神经外科医生的经验。在经验积累的早期较常见的是，破裂发生在显露过程的早期或动脉瘤解剖分离前，通常是由于牵拉和动脉瘤粘连的脑组织，例如指向上的眼动脉(OphA)动脉瘤粘连在额叶，指向下的前交通动脉(ACoA)动脉瘤与视交叉粘连，或后交通动脉(PCoA)动脉瘤与颞叶的粘连。避免牵拉或很少牵拉可以消除这些问题。同样，随着经验的积累夹闭时破裂变得不那么频繁，反映了对何时可以夹闭动脉瘤这种感知的逐步提高。没有经验的神经外科医生对动脉瘤颈解剖分离的不充分和夹闭的不恰当是夹闭时发生破裂的原因，反映了对术中破裂自然的恐惧。经验丰富的神经外科医生更有可能积极地处理动脉瘤并在最后的解剖操作时使动脉瘤破裂，是充分准备下的预期中的动脉瘤破裂，而不是未充分准备下夹闭时的意外动脉瘤破裂。 ■Visceral Response--- 本能反应 Intraoperative aneurysm rupture elicits an intense rush of emotions: surprise, confusion, regret, tension, frustration, anger, excitement, and desperation. This visceral response can be overwhelming and crippling for neurosurgeons early in their surgery experience. These moments demand calm, clarity, and confidence. The adrenaline rush can interfere with microsurgical mechanics. The situation can force dangerous or hasty maneuvers. Calm is needed to quiet the hands and emotions and to execute the plan methodically. In addition, calm benefits everyone in the operating room, from the nurses passing instruments, to the anesthesiologists administering pressors or blood, to other surgeons assisting with the procedure. Clarity is the quality that enables the thinking required in performing the operation. Confidence is the quality that infuses composure and assures that the sequence of technical steps will lead to a successful aneurysm repair. Calm, clarity, and confidence translate into a swift and efficient rupture response. Over time, the technical response to intraoperative rupture becomes reflexive, and the cognitive response becomes intuitive, but the visceral response to rupture does not seem to vanish. Its intensity fades with experience and anticipation, but it remains a factor to deal with. 术中动脉瘤破裂引发强烈而急剧的情绪变化：惊讶、困惑、遗憾、紧张、沮丧、愤怒、兴奋和绝望。神经外科医生在手术经验积累早期，这种本能反应可以是强烈的和有严重后果的。这些情况下需要冷静、头脑清晰和自信。肾上腺素的急剧分泌会干扰显微外科操作。这种情况会迫使术者产生危险或慌乱的动作。需要镇静以稳定双手和情绪，有条不紊地执行计划。此外，镇静对在手术室的所有相关人员，从护士传递器械，麻醉医师管理血压或容量，到其他外科医生协助手术，都有积极的作用。进行操作时需要思考，这要求有清晰的头脑。自信心会使人沉着，使人确信按照技术步骤顺序实施将会成功地把动脉瘤夹闭。心理镇静、头脑清晰和自信心在动脉瘤破裂时可以转化为迅速、有效的反应。随着时间的推移，针对术中破裂的技术反应成为反射性的，并且对破裂的认知也成为直觉性的，但对动脉瘤破裂的本能反应似乎并没有消失。其强度随着处理动脉瘤破裂的经验和对其破裂的预判逐渐降低，但它仍然是一个需要面对的因素。 ■Technical Response---技术性应对措施 The technical response to intraoperative aneurysm rupture is an ordered sequence of steps: tamponade, suction, proximal control with temporary clipping, distal control with temporary clipping, and permanent aneurysm clipping. A small cottonoid is used to cover the rupture site. Gentle pressure and suction effectively clear the surgical field, but firmer pressure and a larger suction may be needed with large tears and brisk bleeding. Bleeding can almost always be controlled with tamponnade and suction, and should not require additional suction from an assistant. Tamponade ties up the suction hand but frees the other hand to place temporary clips on proximal afferent arteries. One-handed clip application is difficult if the point of proximal control has not been adequately dissected. Proximal control slows the bleeding and is often sufficient to finish dissecting and apply permanent clips. Temporary clips on distal efferent arteries may be necessary with brisk back-bleeding. 对术中动脉瘤破裂的技术性应对措施具有固定的步骤：填塞压迫、吸引、临时夹近端控制、临时夹的远端控制和永久夹闭。用小脑棉压在破口。轻柔的压迫和吸引可以有效地看清手术野，但大的裂口和活跃的出血需要坚实的压迫以及更大的吸力。出血几乎总是可以通过填塞和吸引来控制，并不需要助手进行额外的吸引。填塞占用了吸引器这只手，但释放另一只手以便用临时动脉瘤夹夹闭近端的流入动脉。如果近端控制点尚未充分解剖出来，单手夹闭是困难的。近端控制后可以减慢出血速度，通常足以完成解剖分离并进行永久性夹闭。血液快速回流可能需要远端流出动脉的临时夹闭。 An aneurysm that has ruptured intraoperatively is no longer untouchable, as it once was. A torn aneurysm trapped with temporary clips can be collapsed and mobilized aggressively. The sac can be entered, suctioned down, and manipulated. The operation accelerates into “final dissection” mode with the urgency normally associated with temporary clipping and cerebral ischemia. As contrarian as it may seem, intraoperative rupture creates opportunity. For example, an ophthalmic artery aneurysm that ruptures before anterior clinoidectomy can sometimes be clipped without clinoidectomy by aggressively mobilizing the aneurysm away from the anterior clinoid process (ACP). The stress of the situation should not force the permanent clipping before the aneurysm is adequately prepared. An imperfectly placed clip may be used as a tentative clip to control bleeding from the rupture site, remove temporary clips, and reperfuse the brain. Additional permanent clips can be stacked below the tentative clip, or the tentative clip can be readjusted to finalize the repair. 术中动脉瘤破裂不再是不可碰触的，虽然它曾经是。临时夹闭后的撕裂的动脉瘤可以塌陷和大胆推移。可以进入动脉瘤囊，进行吸引和其它操作。紧急情况下手术加速进入“最后解剖分离”模式，常与临时夹闭和有脑缺血有关。从另一方面看，术中动脉瘤破裂也创造了机会。例如，一个眼动脉动脉瘤在前床突切除之前破裂，有时可以通过进一步推移动脉瘤离开前床突，而不进行床突切除的情况下夹闭动脉瘤。这种情形下的压力不应该迫使我们在没有充分的准备之前永久夹闭动脉瘤。一个放置不完美的动脉瘤夹可以作为控制出血点出血的支撑夹，此时可以去除临时夹，恢复大脑供血。另外的永久夹可以放在这个支撑夹之下，或者可以调整这个夹子以达到最终修复。 Cerebral protection with hypothermia and pharmacologic agents is maintained by the anesthesiologists during an intraoperative rupture, and normal or slightly increased blood pressure is maintained during temporary clipping to augment collateral blood flow. 在术中动脉瘤破裂时麻醉医师可以采取低温和药物进行脑保护，临时夹闭过程中维持正常或略高的血压以便增加侧枝循环的血流代偿。 ■Cognitive Response--- 认知反应的形成 The neurosurgeon must continue to think and operate. Intraoperative rupture elicits many questions in the neurosurgeon: Why did the aneurysm rupture? Where is the hole? Why is the aneurysm still bleeding? Where is the other branch artery? How can this be repaired? What was my contingency plan? What did I do when this happened before? All these questions arise while working to control the rupture. Work must continue in order to discern the cause of an aneurysmal rupture, to visualize anatomy under adverse conditions, and to devise a solution. In a surgical field suddenly suffused with blood before an aneurysm has been fully dissected, critical anatomy becomes obscured. The neurosurgeon must see through the blood to find the problem, the undissected anatomy, and the solution. Visual and cognitive insight comes from an appreciation of arterial anatomy and aneurysm pathology. It comes from past aneurysm cases and averted catastrophes during which techniques and tricks have been tried and abandoned or embraced. Every operation on an aneurysm contributes collectively to insight, generating knowledge of aneurysm anatomy that can guide the neurosurgeon when conditions are not so favorable. Answers and solutions during an intraoperative rupture are cognitive, and this cognitive response has to dominate the emotions and guide the hands through critical steps leading from rupture to final clipping. Over time, experience transforms the cognitive response from a forced process to an intuitive one. 神经外科医生必须继续思考并手术。术中破裂引发神经外科医生许多问题：为什么动脉瘤破裂? 破口在哪里? 为什么动脉瘤还在出血? 另外一个动脉分支在哪里? 怎么才能修复? 我的应急计划是什么? 这事以前发生时我是怎么做的? 所有这些问题出现在控制动脉瘤破裂的操作时。必须继续手术以辨别动脉瘤的破裂原因，在不利的条件下看清解剖关系，设计一个解决方案。动脉瘤完全解剖分离清楚之前，手术区域突然弥漫血液，此时关键的解剖就变得模糊起来。神经外科医生必须透过血液发现问题、确定尚未分离结构的解剖关系和解决方案。这种内在的视觉与感知来自于对动脉的解剖和动脉瘤病理的熟悉。它来自于过去的动脉瘤病例和避免灾难事件所尝试的、放弃的或接受的技术和诀窍。对动脉瘤进行的所有操作都有助于洞察力的生成以及动脉瘤解剖细节的积累，从而可以在不利的条件下指导神经外科医生。对动脉瘤术中破裂的回答和解决方案是认知能力。从动脉瘤破裂到完全夹闭，这种认知反应主导着情绪、指导着术者双手完成关键步骤。随着时间的推移，经验转换为一种认知反应，这是一个从被动到主动的过程。 编译者：九江市第一人民医院，神经外科，杨枫，主任医师。 审校：九江市第一人民医院，神经外科，胡炜，主任医师，医学博士。 终审：河南省人民医院，神经外科，张长远。 |
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