神经内镜辅助下经锁孔入路到达鞍区的解剖学比较研究

发布时间：2018-08-22 11:41

【摘要】：目的:比较研究神经内镜辅助显微镜下经眶上锁孔入路、翼点锁孔入路、胼胝体-穹窿间锁孔入路中鞍区重要结构的解剖学特点,并对三种手术入路的显露范围进行定量比较研究。为神经内镜辅助显微镜下经锁孔入路治疗鞍区病变提供局部应用解剖学资料,为临床中治疗鞍区病变选择适当的手术入路提供理论指导。方法:将福尔马林溶液固定的5具带颈成人尸头标本以酒精浸泡,解剖颈部血管,插管冲洗,灌注乳胶。然后分别采用经眶上锁孔、翼点锁孔和胼胝体-穹窿间锁孔三种手术入路开颅,模拟手术过程,通过手术显微镜及神经内镜对鞍区结构进行解剖观察,比较不同锁孔入路的切口及骨窗、鞍区各手术间隙在模拟手术过程中的应用价值。去除部分颅骨及脑组织后测量相关数据,应用Heron’s公式计算出各手术入路下鞍区的暴露范围,采用SPSS14.0软件进行统计分析后,比较各手术入路的显露范围。结果:(1)数据结果:经眶上锁孔入路、翼点锁孔入路、胼胝体-穹窿间锁孔入路对鞍区的显露面积分别为:279.33±13.633渵2、290.55±14.553渵2、86.47±5.333渵2。翼点锁孔入路比眶上锁孔入路显露范围大,差异有统计学意义(P0.05);眶上锁孔入路比胼胝体-穹窿间入路显露范围大,差异有统计学意义(P0.05);翼点锁孔入路比胼胝体-穹窿间入路显露范围大,差异有统计学意义(P0.05)。(2)应用神经内镜可以不牵拉重要神经、血管等结构而经其间狭小的间隙达到对深部视野全景化的观察,可以消除显微镜下的视野盲区,而且对细微结构特别是穿支小血管的显示较清晰。(3)经眶上和翼点锁孔入路在显微镜下和用不同角度的神经内镜在不同解剖间隙内操作都能较好的显露和观察鞍区的重要结构,包括前床突、视神经、视交叉、鞍膈、垂体柄、Willis环及细小的穿支动脉、鞍背、后床突、动眼神经等,并可看到基底动脉顶部和脑干腹侧结构。经胼胝体-透明隔-穹窿间锁孔入路对大脑前动脉A1段、前交通动脉,视交叉和视束的暴露和观察较好。(4)经眶上锁孔入路对第Ⅰ、Ⅱ、Ⅳ间隙暴露较好,第Ⅲ间隙只能部分暴露。在第I间隙可清楚地观察视交叉,视神经、垂体柄、鞍膈、双侧颈内动脉和后交通动脉、垂体前叶。进入第Ⅱ间隙可见颈内动脉和后交通动脉及其穿支动脉。经第Ⅲ间隙向后打开Liliequist膜进入脚间池,可见基底动脉分叉部、双侧大脑后动脉、小脑上动脉、动眼神经。牵开额叶直回,经第Ⅳ间隙可观察大脑前动脉、前交通动脉和Heubner返动脉。(5)经翼点入路对鞍区各间隙均可显露,对第Ⅱ、Ⅲ间隙的显露最佳,进入第1、Ⅳ间隙需斜行。该入路能从侧方更清楚地观察颈内动脉、后交通动脉和脉络膜前动脉及其穿支动脉。后交通动脉和动眼神经与小脑幕游离缘之间无穿支动脉,经该间隙向后打开Liliequist膜后,越过后床突进入脚间池,可见基底动脉分叉部、双侧大脑后动脉、小脑上动脉及动眼神经,并可观察脑干腹外侧面。切除额叶直回后可斜行进入第Ⅳ间隙。(6)经胼胝体-透明隔-穹窿间锁孔入路对第Ⅳ间隙显露最佳,但无法显露其它间隙。结论:(1)三种入路对鞍区的显露范围不同,翼点锁孔入路显露的面积最大,眶上锁孔入路次之,经胼胝体-穹窿间锁孔入路最小。(2)在神经内镜辅助显微镜下经眶上、翼点锁孔入路都能观察到鞍区及其周围的重要神经、血管等结构,包括基底动脉及其分支和脑干腹侧面结构,经胼胝体-透明隔-穹窿间锁孔入路显露鞍上和三脑室前部结构较清晰。(3)神经内镜具有多角度视野、巨大的景深、可以随镜体深入延伸视野等优点,可以消除手术操作中显微镜下的视野盲区。在模拟手术入路过程中,应用神经内镜可以不牵拉重要神经、血管等结构而经其间狭小的间隙达到对深部视野全景化的观察,而且对细微结构特别是穿支小血管的显示较清晰,优于显微镜。(4)不同手术入路具有不同优势。经眶上锁孔入路对于鞍区第I、Ⅱ间隙显露较好,能充分显露Willis环前部,视野较为直接,对中线部位、同侧鞍旁及部分对侧结构的显露较充分。经翼点锁孔入路对鞍区四个手术间隙及全部Willis环均可显露,对鞍上、同侧鞍旁和鞍后均可显露,尤其对第Ⅱ、Ⅲ间隙的显露最具优势,而且经第Ⅲ间隙能清楚地观察到后交通动脉的全长和穿支动脉。经胼胝体-透明隔-穹窿间锁孔入路对第Ⅳ间隙的显露最直接,对鞍上后部和第三脑室前部显露较好。
[Abstract]:Objective:To compare the anatomical characteristics of the important structures in the sellar region through supraorbital keyhole approach,pterional keyhole approach and callosal-fornix keyhole approach under neuroendoscope-assisted microscope,and to quantitatively compare the exposure ranges of the three surgical approaches. Local applied anatomical data can provide theoretical guidance for the selection of appropriate surgical approaches for the treatment of sellar lesions.
Methods: Five adult cadaveric heads with cervix fixed by formalin solution were immersed in alcohol, dissected the cervical vessels, washed with intubation and perfused with latex. Anatomical observation was carried out to compare the application value of incision and bone window of different keyhole approaches and surgical space in the sellar region in the simulated operation process. The extent of exposure.
Results: (1) Data Resul: (1) The exposed area of suporbitakeyhole approach, pterkeyhole approach, corpus callosum-forniculinterkeyhole approach to the sellar region was 279.33 (+ 13.63) 2, 290.55 (+ 14.55) 2, 86.47 (+ 5.33 (+ 5.33) 2) 2, 86.47 (+ 5.33) 2. The exposearea of pterkeyhole approach was significantly larger than supororbitakeyhole approach (P 0.05); the exposearea of supsupsupsuporororbitakeyhole approach was 279.33 (+ 13.63) 2, 2, 2, 20.55 (+ 14.33 (+ 14.63) 2, 86.47 (+14.55 (+ 14.55 (+2), In the meantime, it is necessary to study the relationship between the two. Body-fornix approach showed a wide range of exposure, the difference was statistically significant (P 0.05); pterional keyhole approach than the callosal-fornix approach revealed a larger range, the difference was statistically significant (P 0.05). (2) The application of neuroendoscopy can not pull important nerves, blood vessels and other structures through the narrow gap between the deep visual field panoramic observation, can be. (3) The important structures of the sellar region, including the anterior clinoid process, optic nerve and optic chiasma, can be well exposed and observed through the supraorbital and pterional keyhole approach under microscope and by neuroendoscopy with different angles in different anatomical spaces. Sellar diaphragm, pituitary stalk, Willis ring and fine perforator artery, dorsal sellar, posterior clinoid process, oculomotor nerve, and the top of basilar artery and ventral structure of brainstem can be seen. The exposure and observation of A1 segment of anterior cerebral artery, anterior communicating artery, optic chiasma and optic tract by transcorbital keyhole approach are better. The interval I I, IV was well exposed and the interval I I I was only partially exposed. The optic chiasma, optic nerve, pituitary stalk, sellar diaphragm, bilateral internal carotid artery and posterior communicating artery, anterior pituitary lobe were clearly observed in the interval I. The internal carotid artery, posterior communicating artery and its perforating artery were visible in the interval I I. The Liquist membrane was opened backwards into the foot through the interval I I I. The bifurcation of basilar artery, bilateral posterior cerebral artery, superior cerebellar artery and oculomotor nerve can be seen in the cistern. The anterior cerebral artery, anterior communicating artery and Heubner's recurrent artery can be observed through the fourth space after the frontal lobe is pulled apart. The internal carotid artery, the posterior communicating artery, the anterior choroidal artery and their perforating arteries can be observed more clearly through the lateral approach. The superior cerebellar artery and the oculomotor nerve can be observed on the ventrolateral side of the brainstem. After the frontal lobe is resected, it can obliquely enter the space IV. (6) The keyhole approach through the corpus callosum-septum pellucidum-fornix is the best way to expose the space IV, but other spaces can not be exposed.
CONCLUSIONS: (1) Three approaches have different exposure ranges to the sellar region, the pterional keyhole approach has the largest exposure area, the supraorbital keyhole approach is the second, and the transcorpus-fornix keyhole approach is the smallest. (2) Under the neuroendoscope-assisted microscope, the pterional keyhole approach can observe the important nerves and blood vessels around the sellar region, including the base. The basilar artery and its branches and ventral brainstem structures were clearly revealed through the corpus callosum-septum pellucidum-fornix keyhole approach. (3) Neuroendoscopy has many advantages, such as multi-angle vision, huge depth of field, and can extend the field of vision with the lenses deeply. It can eliminate the blind area under the microscope in the operation. During the operation, endoscopic neuroendoscopy can achieve panoramic observation of deep visual field without pulling important nerves and blood vessels through the narrow space between them, and it is better than microscopy in displaying fine structures, especially perforating vessels. (4) Different surgical approaches have different advantages. The anterior part of the Willis ring can be fully exposed, and the visual field is direct. The median part, the ipsilateral parasellar and some contralateral structures are fully exposed. The length of the posterior communicating artery and the perforating artery could be clearly observed through the third space.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2011
【分类号】：R322

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