扩大经蝶窦入路的显微解剖研究

发布时间：2018-05-31 13:48

本文选题：扩大经蝶窦入路 + 手术入路　；参考：《山东大学》2006年硕士论文

【摘要】：经蝶窦入路经过近百年的发展以其微创、并发症发生率低和术后死亡率低已经成为鞍区肿瘤的首选手术入路。1987年Weiss首先命名并描述了进一步切除鞍结节和蝶骨平台后部、切开鞍隔上硬膜的扩大经蝶窦入路。这一改良为鞍上结构与肿瘤鞍上部分的显露提供了很好的术野，同时避免了脑牵拉。经过不断改进，近年来扩大经蝶入路应用范围逐步扩大，用于处理向前到蝶骨平台、向侧方侵及海绵窦、向后达鞍背中上斜坡的肿瘤均已成为可能。本研究模拟扩大经蝶入路，对相关显微解剖结构进行测量，以期为临床手术提供参考数据，初步探讨其基于解剖基础的改进策略。目的：观察测量扩大经蝶窦入路相关的显微解剖结构，为临床手术提供参考和依据。方法：5例颅骨干标本，观察熟悉相关骨性结构及其解剖关系；3例尸头正中矢状面切开共6侧，显微镜下解剖相关结构并测量和拍照；5例完整尸头，与3例带硬膜颅底标本显微镜下模拟手术入路，对涉及的结构进行显微解剖学观测和拍照，其中3例尸头模拟神经内镜辅助手术。结果：①以前鼻棘为入路起点，至蝶窦口、筛后孔、蝶腭孔、翼管前口、展神经硬膜入口的距离分别为(56.61±4.67)mm、(64.88±4.43)mm、(50.12±2.20)mm、(59.94±3.31)mm、(61.00±2.73)mm。以鼻腔底平面为基线，上述诸结构连线在矢状面投影线与基线夹角(基底角，下同，见图1)分别为(33.1±3.7)°、(36.3±7.43)°、(29.1±3.6)°、(23.9±3.3)°、(28.1±3.6)°。②视神经隆起仅位于蝶窦内的27.3％，隆起仅位于筛窦内27.3％，，同时位于筛窦和蝶窦内40.9％；蝶窦内视神经—颈内动脉隐窝出现率68.2％，鼻前棘至隐窝距离(76.16±5.32)mm，基底角(35.8±4.2)°。③眼动脉起始点距鼻前棘分别为(72.88±6.78)mm，基底角(30.3±3.7)°，鼻前棘至破裂孔距离(79.38±5.32)mm，基底角(32.7±3.9)°，蝶窦内颈内动脉隆起出现率68.2％，扩大经蝶窦入路切除海绵窦腹侧、视神经—颈内动脉隐窝、视神经管后部以及岩尖部分骨质可较充分游离颈内动脉，尤其在神经内镜辅助下海绵窦内及前床突周围分支发出点均可探及。④展神经硬膜入口双侧距离(19.76±1.98)mm，与后床突垂直距离(25.66
[Abstract]:Transsphenoidal approach has become the preferred approach for Sellar region tumors after nearly 100 years of development, with low incidence of complications and low postoperative mortality. In 1987, Weiss first named and described the further resection of Sellar nodules and posterior sphenoid plateau. Incision of the suprasellar dura mater via transsphenoidal approach. This improvement provides a good surgical field for the exposure of the suprasellar structure and the suprasellar part of the tumor, while avoiding brain retraction. After continuous improvement, the application scope of transsphenoidal approach has been gradually expanded in recent years to deal with tumors that advance to the sphenoid platform, lateral into the cavernous sinus and reach back to the middle and upper slope of the saddle. In this study we simulated the expansion of transsphenoidal approach and measured the related microanatomical structures in order to provide reference data for clinical operation and discuss the improvement strategy based on anatomical basis. Objective: to observe and measure the microanatomical structure related to the expanded transsphenoidal approach and to provide reference for clinical operation. Methods the bone structure and its anatomic relationship were observed in 5 cases of cranial dry bones. 6 sides of the middle sagittal plane of 3 cadaveric heads were dissected. The related structures were dissected under microscope and 5 cases of intact cadaveric heads were measured and photographed. Microanatomical observations and photographs of the structures involved were performed in 3 cases with dural skull base specimens under the microscope, including 3 cases of cadaveric head simulated neuroendoscopy assisted surgery. Results the distance from the anterior nasal spine to the orifice of sphenoid sinus, posterior ethmoid foramen, sphenopalatine foramen, anterior orifice of pterygoid canal and the dural orifice of abductor nerve was 56.61 卤4.67mm, 64.88 卤4.43m, 59.94 卤3.31mm and 59.94 卤2.73mmmrespectively. Taking the bottom plane of the nasal cavity as the baseline, the lines of the above structures are at the angle between the projection line of the sagittal plane and the baseline (the base angle, the same as below). Fig.1) the optic nerve eminence is only 27.3mm in the sphenoid sinus, and only 27.3mm in the ethmoid sinus, 40.9% in the ethmoid sinus and 40.9 in the sphenoid sinus. The occurrences of the optic nerve and carotid artery recess in the sphenoid sinus are 68.2mm, the distance between the anterior nasal spine and the recess is 76.16 卤5.32mm, the distance between the anterior nasal spine and the recess is 76.16 卤5.32mm. 35.8 卤4.2) 掳.3 the distance between anterior nasal artery and anterior nasal spine was 72.88 卤6.78 mm, 30.3 卤3.7 掳, 79.38 卤5.32 mm and 32.7 卤3.9 掳, respectively. The incidence of internal carotid artery protuberance in sphenoid sinus was 68.2 掳, and the ventral cavernous sinus was resected via transsphenoidal approach. The medial carotid artery recess, the posterior part of the optic canal and the petrous apex of the optic nerve can fully dissociate the internal carotid artery. In particular, the bilateral distance between the adductor dural entrance (19.76 卤1.98) and the vertical distance from the posterior clinoid process to the posterior clinoid process can be detected at the point of origin within the cavernous sinus and around the anterior clinoid process under endoscopy.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2006
【分类号】：R322

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