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》著作第一期。本期主要内容为 在显微镜下操作技巧，《Seven Aneurysms 》系列内容包括 SectionI 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.临时阻断；6.永久夹闭；7.检测；8.脑皮层造瘘；9.术中破裂. SectionII The Approaches: 10.翼点入路; 11.眶颧入路; 12.前纵裂入路; 13.远外侧入路. SectionIIIThe 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.
1. Under the Microscope 在显微镜下操作
The Microscope 显微镜
The operating microscope is the neurosurgeon’s most important tool. It illuminates the operative field, magnifies anatomy, and gives constant visual feedback. Skillful dissection depends on seeing all relevant anatomy and controlling every maneuver, and the microscope empowers us by enhancing sight well beyond the physiologic limit of unaided eyes. However, this unwieldy piece of equipment must be adapted to our individual anatomy and move fluidly with our movements. A finely tuned microscope extends visual perception with imperceptible effort. Therefore, the microscope must be tuned before every case, checking the microscope stand, mouthpiece, oculars, chair, and foot pedals.
手术显微镜是神经外科医生最重要的工具，它为术野照明，将解剖结构放大，并持续提供视觉反馈信息。娴熟的解剖需要看到所有相关的解剖结构，能够控制显微镜的每一步操作。显微镜能够增强我们的视力，超过了裸眼的生理极限。然而，这个庞大的设备必须适合我们术者个体的解剖特点，能随着我们的活动而顺畅移动。一台精细调校的显微镜能够毫不费力地扩展视觉感知能力。因此，在每次使用前，必须对显微镜做相应的调整，包括检查显微镜的平衡臂、口控开关、目镜、操作椅和脚踏。
The microscope can move fluidly with the neurosurgeon because the counterbalancing stand makes it weightless. Brakes in the stand’s joints hold the microscope’s position, but the microscope floats when the brakes are released. The microscope must be balanced precisely to keep it from drifting, tipping, or feeling heavy. The microscope balances optimally when the stand’s vertical and horizontal beams are at right angles. A stand that overreaches or collapses on itself will drift despite being balanced properly. Therefore, the stand should be positioned beside the patient’s head at an appropriate site and distance to achieve this right angle.
由于平衡臂使它失去重量，所以显微镜可以随着神经外科医生轻松地移动。刹住显微镜平衡臂的关节，就可以使它保持不动，如果松开制动开关，显微镜就处于漂浮状态。显微镜必须要精确地调平衡，以免漂移，倾斜或感觉沉重。显微镜理想的平衡状态是平衡臂的竖梁和横梁呈直角。尽管显微镜原来已经调平衡，但是平衡臂活动伸展或下坠时，显微镜仍然会漂移。因此，为了达到直角，平衡臂应该以合适的位置和距离放置在病人头旁边。
The Mouthpiece 口控开关
Some who have used the mouthpiece abandon it after a short trial, saying that it is awkward, uncomfortable, and causes gagging. Those who persist in using it find that they can no longer operate without it. The mouthpiece unlocks the microscope’s potential, allowing the neurosurgeon to constantly focus and refocus without using hands, thereby increasing operative pace and efficiency. If the microscope is the tool that enables neurosurgeons to see, then the mouthpiece is the tool that enables them to see clearly. It releases the stand’s vertical brakes to make fine adjustments that bring the operative target into focus. The target depth changes constantly during the dissection, particularly at high magnification, and the microscope must follow. The mouthpiece enables these adjustments to be made with small head movements without having to put down instruments, change the focal length, or interrupt the rhythm of surgery. The head moves naturally to areas of interest, whereas foot movements on the pedals are not a natural way to refocus. The mouthpiece is not meant for major changes in the microscope’s orientation; these movements still require the use of two hands to release all brakes.
一些人在短暂地尝试显微镜的口控功能后就放弃了，认为它很笨拙、不方便并且使人想吐。另外一些坚持使用该功能的人发现离开它就不能手术了。口控功能充分发挥了显微镜的内在潜能，使得医生不用手控就可以不停地聚焦和调焦，因此提高了显微手术的速度和效率。如果说显微镜是一个让医生可以看的工具，那么口控就是一个让医生看得清楚的工具。它解除了显微镜的垂直制动功能，能够对手术目标的聚焦进行精细调整。由于在显微分离的过程中，尤其是在高倍放大的时候，目标深度总是在不停的变化中，而显微镜必须随之调整。口控功能使得微小的头部移动就可以完成这些调整，同时不需要放下手术器械、改变焦距长度或打乱手术节奏。头部往往很自然的会移动到感兴趣的术野，而在踏板上的脚移动起来就会比较别扭。当然，口控不是用来对显微镜方向进行大的移动，这些移动仍然需要利用双手对显微镜进行全面解锁。
The mouthpiece must be carefully fitted with the fixed, upper plate of the mouth switch lying below and in contact with the upper two front teeth. Each neurosurgeon has a unique distance between the interpupillary line and the inferior edge of the front teeth. Another setting adjusts the anterior-posterior position so that it sits comfortably in the mouth. The switch is activated by biting the lower plate with the lower teeth, thereby releasing the stand’s brakes and moving the microscope. The line of sight into the ocular lenses must be maintained with both the biting motion and the head movement to maintain visual feedback; the mouthpiece is not properly set if biting the mouth switch compromises vision. Releasing the mouth switch relocks the microscope into the desired position.
口控开关必需仔细安装固定，嘴部开关的上板放在上门齿的下面并与之接触。从瞳孔连线到门齿下缘的距离每个医生都有不同。另外一项是调整口控开关的前后位置，使得其在嘴里舒适。用下牙齿咬开关的下板启动口控开关，从而对平衡臂解锁、移动显微镜。在咬合动作和头部移动时必需保持视线在目镜内以维持视觉反馈。如果咬合口里的开关时影响视野，那就是口控开关调整得不合适。释放口里的开关，重新锁定显微镜到合适的位置。
Ocular lenses are adjusted for interpupillary distance, length of the tube, and diopters. An inaccurate interpupillary setting can compromise binocular vision. A tube length that is too long can shadow or constrict the visual field, and one that is too short can rub the nose against the ocular’s bridge. The diopter setting is individualized to avoid visual straining during long procedures.
目镜要根据瞳孔的距离、镜筒的长度和屈光度调整合适，不精确的瞳距设置会导致重影。目镜的长度如果太长会遮挡或限制视野，如果太短则会使目镜连结桥蹭鼻子。屈光度的设置要个体化，避免长时间操作导致的视觉变形。
The Chair 座椅
Microsurgery is performed best with the neurosurgeon sitting comfortably. This has nothing to do with strength or stamina; sitting in a chair with armrests allows us to relax our hands. Dexterity is necessary for microsurgical proficiency, and it improves when there is no contractile tone in our arm and forearms. The height of the armrest is adjusted to slouch the shoulders slightly and brace the forearms and wrists. The seat height is adjusted relative to the table height to dangle the hands above the operative field with slight wrist flexion. Most chairs allow the arm rests to be angled up or down, and rotated inward or outward. When these adjustments have been made, the armrests are secured tightly. The hands are in optimal position when almost no muscle tone is needed to hold the instruments in the surgical field. A setup that requires wrist extension or any antigravity tone may induce tremor. The movement needed to control the instruments is minimal and comes from the fingers. Armrests alone should stabilize and relax the hands, but the hypothenar eminence or an extended fifth finger can also be used. Gently setting the hands on the edge of the field can further relax the hands.
完美的显微手术需要手术医生坐姿舒适。这与体力和耐力无关，坐在有臂托的椅子上可以使双手放松。娴熟的显微外科手术必需要有灵活性。当我们的上臂和前臂没有对抗性张力时就可以提高灵活性。臂托的高度要调整到使整个肩膀轻轻自然低垂，同时前臂和手腕都能得到有效的支撑。椅子的高度要与手术床的高度相对应，并使操纵者的双手自然下垂到术区，保持手腕轻度屈曲。多数座椅允许臂托上下成角调节和内外旋转调节，当调节好后，臂托要安全固定。此时，双手放置在臂托上，当你在使用器械进行显微操作时不感觉到肌肉的收缩和用力就为最佳状态。任何调整如果感觉手腕有伸展或对抗重力作用都会导致震颤。任何显微镜下的移动需要尽可能幅度微小并来自于手指的精确调节。臂托仅仅用来固定和放松双手，此时，处在高位的小鱼际肌肉或扩大到第五指关节也可以充分的利用起来，轻轻地将双手置于术野的边缘可以进一步起到放松双手的作用。
The chair should roll freely in the space under the microscope. Subtle shifts in body position are necessary to align the hands to the surgical field and keep them relaxed. Power cords and cables are routed behind the chair to keep them from getting in the wheel track and limiting the chair’s mobility.
座椅应该可以在显微镜下的空间自由移动。为使双手与术区保持一致并保持放松，身体位置的轻微移动是必须的。电源插头和电缆线在座椅的后方走过，避免它们绕进座椅的轮轨而限制其移动。
The Foot Pedals 脚踏开关
Microsurgery is performed best at high magnification, requiring constant zoom adjustments with the foot pedal while keeping the hands free to dissect. One foot is dedicated to controlling the microscope’s zoom, and the other is dedicated to controlling bipolar cautery. Good chairs have integrated zoom and focus controls that minimize clutter underfoot. Otherwise, the microscope’s foot box is placed at the base of the chair. The mouthpiece minimizes the need for focusing with the foot control. The pedals should be positioned comfortably underfoot to be ready at any time and to relax the legs, which helps keep the body core and hands relaxed.
显微手术最好在高倍放大镜下操作，需要用脚踏开关不断调整放大倍数以解放出来双手用于分离操作。一只脚控制显微镜放大倍数的调节，另一只脚控制双极电凝。好的座椅将放大倍数和焦距控制功能进行整合，尽量减少脚下杂乱。或者，将显微镜的脚踏盒放在座椅底座，口控开关也有起到减少脚控调焦的作用。脚踏应该放置在脚下舒适的位置，便于随时可以轻松的控制，并放松双腿，这样可以是保持身体和双手处于放松状态。
These adjustments and settings are a prerequisite for any aneurysm operation. Performing the various steps described here becomes routine, and they can be done quickly. When fully adjusted, the microscope is tuned to our bodies and moves fluidly with our movements, which keeps the focus on dissecting and clipping the aneurysm.
对于任何动脉瘤手术，这些调节和安放都是事先必需做到位的。这里描述的各个步骤的执行是常规进行的，所以能够很快完成。当显微镜都调整完毕后，它就可以和我们的身体适配，随着我们的移动而流畅地移动。这使我们能够将注意力集中在分离和夹闭动脉瘤上。
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