后开颅内窥镜铺助锁孔手术入路的显微解剖学和临床应用研究

发布时间：2018-05-11 19:26

本文选题：锁孔入路 + 松果体区　；参考：《安徽医科大学》2006年硕士论文

【摘要】：目的：锁孔手术是微创神经外科学的重要分支，它强调采用最直接准确的路径到达颅内病灶，不过多暴露和干预周围正常脑组织和神经血管结构，充分利用颅内自然间隙处理病变，使手术效果最好而手术创伤最小。迄今为止，文献报道的锁孔手术主要是处理幕上病变，本文统称之为前开颅锁孔手术。有关幕下病变，包括松果体区病变锁孔手术的报道较少，，本文将这类锁孔手术统称为后开颅锁孔手术。为了更好地开展后开颅锁孔手术，我们选择常用的4种后开颅手术入路进行相应的锁孔入路显微外科解剖学和临床应用研究。方法：1．解剖研究：在8具福尔马林固定的尸头标本上，分别模拟经枕幕上和幕下小脑上到松果体区锁孔手术入路、乙状窦后到桥小脑角锁孔手术入路、经小脑延髓裂到四脑室锁孔手术入路开颅，观察显露范围和神经血管毗邻关系，各关键步骤显露后用数码相机拍摄显微镜和内窥镜下照片。(1)经枕下幕上锁孔入路：在横窦和上矢状窦外上方形成骨窗，抬起枕叶到达环池后部，分离蛛网膜，显露基底静脉，进入四叠体池，观察第三脑室后部、四叠体、大脑大静脉系统各血管间隙。(2)幕下小脑上锁孔入路：在枕外粗隆下正中形成骨窗，经小脑幕和小脑上蚓间隙，需切断上蚓部和小脑半球上表面内侧部回流至横窦和小脑幕的桥静脉，分离四叠体池蛛网膜后壁进入四叠体池，观察四叠体区各结构。(3)乙状窦后锁孔入路：距耳根3.cm作纵向直切口，起自上项线上1cm处，长约6cm。在乙状窦和横窦内下方形成骨窗，分离小脑延髓侧池和桥小脑角池蛛网膜，观察桥小脑角区的神经血管，并经上中下神经间隙观察桥脑延髓前外侧方。(4)小脑延髓裂锁孔入路：枕下正中开颅，自枕大孔后缘向上形成2.5×3.0cm~2大小的骨窗，分离枕大池蛛网膜，分离扁桃体延髓裂、扁桃体脉络膜裂、外侧裂、蚓垂体和小脑内侧间隙，显
[Abstract]:Objective: keyhole surgery is an important branch of minimally invasive neurosurgery, which emphasizes the most direct and accurate path to the intracranial lesions without excessive exposure and intervention of the surrounding normal brain tissues and neurovascular structures. Make full use of the intracranial natural space to deal with the lesions, so that the operation is the best and minimal surgical trauma. So far, the keyhole surgery reported in the literature mainly deals with supratentorial lesions, which is called anterior craniotomy keyhole surgery. There are few reports about subtentorial diseases, including pineal region keyhole surgery. This kind of keyhole surgery is called posterior craniotomy. In order to better carry out the posterior keyhole operation, we chose four common posterior craniotomy approaches to study the microsurgical anatomy and clinical application of the keyhole approach. Method 1: 1. Anatomical study: on 8 formalin fixed cadaveric head specimens, we simulated the keyhole approach from supratentorial and subtentorial cerebellum to pineal region, and from posterior sigmoid sinus to pontocerebellopontine angle keyhole approach, respectively. Craniotomy was performed through the cerebellar medullary fissure to the fourth ventricle keyhole to observe the exposure area and the relationship between nerve and blood vessels. After the key steps were exposed, the microscopes and endoscopy were taken with digital camera. The keyhole approach was made through the suboccipital keyhole: the bone window was formed above the transverse sinus and the superior sagittal sinus, the occipital lobe was raised to the posterior part of the cistern, the arachnoid was separated from the arachnoid, and the basilar vein was exposed. Enter the cistern, observe the posterior part of the third ventricle, the tetraad, and the intervascular space of the great cerebral vein system) the subepithecal keyhole approach: form a bone window through the tentorium cerebelli and the space between the vermis of the cerebellum in the middle of the extraoccipital protuberance. The superior vermis and the medial surface of the cerebellar hemisphere should be cut off to the pons veins of the transverse sinus and tentorium, and the posterior arachnoid wall of the quadriassic cistern should be separated into the tetrad cistern. The retrosigmoid keyhole approach was observed in each structure of the quadrilateral region: a longitudinal and straight incision was made from the root of the ear to 3.cm, which was about 6 cm in length from the 1cm on the superior nape line. Bone window was formed under sigmoid sinus and transverse sinus to separate the arachnoid of the lateral medullary cistern and the pontocerebellum angle cistern, and to observe the nerve vessels in the cerebellopontine angle area. The keyhole approach of cerebellar medullary fissure was observed through the space of superior middle and inferior nerve. The craniotomy was performed in the middle of the occipital, and a 2. 5 脳 3.0cm~2 bone window was formed from the posterior margin of the foramen magnum, the arachnoid of the cistern magnum was separated, and the medullary fissure of the tonsils was separated. Choroidal fissure of tonsil, lateral fissure, medial space between vermis pituitary and cerebellum.
【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2006
【分类号】：R651;R322

【参考文献】