乙状窦前经颞骨岩部锁孔入路的显微解剖学研究
发布时间：2018-07-15 22:08
【摘要】： 第一部分乙状窦前迷路后锁孔手术入路设计的显微解剖学研究 目的:遵循微创化的原则,将微创锁孔手术理念融入乙状窦前入路,探讨乙状窦前迷路后锁孔手术的可行性和手术入路设计,观察显露的解剖结构,为临床应用提供依据。 方法:采用8具经福尔马林固定、颅内动静脉分别用彩色乳胶灌注的尸体头颅标本。按照“尽量小、足够大”的原则,在传统乙状窦前经颞骨岩部入路切口的基础上,探索性地逐步缩小皮肤切口,最后形成耳后“C”形长度约7cm的头皮切口。分别向前翻开皮瓣和肌筋膜瓣,磨除部分乳突再联合颞部开颅,形成大小约3.5cm×3cm的豌豆形骨窗;打开乙状窦前和颞部硬脑膜,结扎、切断岩上窦,牵开颞叶和小脑半球,显微镜下观察所显露的解剖结构。 结果:耳后7cm“C”形头皮切口和3.5cm×3cm大小的骨窗完全可以满足入路相关重要结构的显露。通过调整头位和显微镜角度,乙状窦前迷路后锁孔入路可显露同侧动眼神经、滑车神经、三叉神经、面听神经复合体、舌咽神经、迷走神经、后交通动脉、大脑后动脉、小脑上动脉、小脑前下动脉、基底动脉中上段、上斜坡、桥脑腹外侧面、海绵窦后部结构。 结论:实验设计的乙状窦前迷路后锁孔入路具有临床应用可行性,可很好地显露上述结构。理论上,通过该锁孔入路可进行桥脑腹外侧肿瘤、单侧桥脑海绵状血管瘤、局限的上岩斜区脑膜瘤、未侵及内耳道的听神经瘤、基底动脉中上段动脉瘤等手术。 第二部分神经导航辅助乙状窦前经迷路锁孔入路的解剖学研究 目的:将微创锁孔手术理念融入乙状窦前入路,在神经导航辅助下,设计乙状窦前经迷路锁孔入路(包括经部分迷路及岩尖锁孔入路和经全迷路锁孔入路两种手术方式),探讨精确磨除入路相关骨质结构的可行性,为临床应用提供依据。 方法:采用8具经4%甲醛固定、颅内动静脉乳胶灌注的成人尸头,实验前建立术中导航资料。在导航系统中用不同颜色标出乙状窦、骨迷路、内耳道等重要结构的范围。采用迷路后锁孔入路的切口和骨窗,分层向前翻开皮瓣和肌筋膜瓣,导航下轮廓化乙状窦、骨半规管、面神经管,依次磨除部分迷路及岩尖、全部迷路,观察显露结构的差异,测量显露结构的长度、手术视野和乙状窦前间隙最大术野角度。 结果:1、迷路后锁孔手术入路的切口可完全满足经迷路锁孔入路的要求。2、在术前规划的前提下,神经导航可辅助精确完成乙状窦、骨半规管的轮廓化和部分迷路及岩尖、内耳道上结节、全部迷路的磨除,可减少盲目磨除造成的重要结构的误伤。3、同迷路后锁孔入路比较,经部分迷路及岩尖锁孔入路可明显增加斜坡、面神经颅内段和展神经的显露长度、水平视野和垂直视野、乙状窦前间隙最大术野角度(均P0.01)。4、经全迷路锁孔入路中,上述硬膜下结构显露长度、乙状窦前间隙最大术野角度较迷路后锁孔入路也明显增加(均P0.01),但同部分迷路及岩尖锁孔入路比较,差异无统计学意义(均P0.05)。 结论:乙状窦前经迷路锁孔入路具有可行性,可良好显露岩斜区,符合微创理念。神经导航系统可辅助精确完成入路相关的骨质结构磨除。部分迷路及岩尖或全迷路磨除均可改善岩斜区的显露。经部分迷路及岩尖锁孔入路可广泛显露岩斜区、桥脑小脑角、小脑幕上区、桥脑前区和海绵窦后部III-XI脑神经之间的结构,且听力和面神经功能得以保留的可能性较高。经全迷路锁孔入路的观察和操作角度更多,但进一步增加的显露有限,且需牺牲听力。 第三部分神经导航辅助下乙状窦前经颞骨岩部锁孔入路至岩斜区的量化研究 目的:在神经导航辅助下,定量分析乙状窦前经颞骨岩部锁孔入路四种手术方式对岩斜区显露的差异,提供临床应用依据。 方法:将乙状窦前经颞骨岩部锁孔入路按操作先后顺序依次分为四种手术方式:迷路后锁孔入路,经部分迷路及岩尖锁孔入路,经全迷路锁孔入路和经耳蜗锁孔入路。采用6具(12侧)经4%甲醛固定、颅内动静脉乳胶灌注、已建立导航资料的成人尸头行显微解剖,依次模拟上述锁孔入路。运用Stryker神经导航系统依次测定每种入路的岩斜区显露面积和手术操作自由度,统计学分析处理。 结果:1、四种锁孔入路的岩斜区显露面积依次为(93.1±17.6)mm2、(340.1±47.1)mm2、(357.4±56.4)mm2、(377.5±59.4)mm2;迷路后锁孔入路显著小于后三种术式(均P0.01),后三者相互之间无显著差异(均P0.05)。2、手术操作自由度依次为(555.1±164.1)mm2、(714.1±203.8)mm2、(847.2±186.7)mm2、(906.8±204.6)mm2;经部分迷路及岩尖、经全迷路、经耳蜗三种锁孔入路均明显高于迷路后锁孔入路(均P0.01),经全迷路和经耳蜗两种锁孔入路均高于经部分迷路及岩尖锁孔入路(均P0.01),但经全迷路和经耳蜗锁孔入路之间、经部分迷路及岩尖和经全迷路锁孔入路之间均无显著差异(均P0.05)。 结论:四种手术方式的创伤依次增大。迷路后锁孔入路理论上不损伤听力和面神经功能,其对岩斜区的显露相对有限。经部分迷路及岩尖锁孔入路的显露范围更广,且面神经功能和听力得以保留的可能性较高。经全迷路锁孔入路对病变处理更为方便,但并不能进一步增加岩斜区的显露。经耳蜗锁孔入路也不能进一步增加岩斜区的显露,但适用于侵及岩段颈内动脉的病变的手术。
[Abstract]:Microsurgical anatomy of the approach of the retrosigmoid posterior keyhole approach
Objective: to follow the principle of minimally invasive surgery, integrate the concept of minimally invasive keyhole surgery into the anterior approach of the sigmoid sinus and explore the feasibility and surgical approach design of the posterior sigmoid labyrinthine keyhole operation, and observe the exposed anatomical structure to provide the basis for clinical application.
Methods: 8 cadaver cranial specimens were perfused with color emulsion by formalin fixation. According to the principle of "small and large enough", the skin incision was gradually reduced on the basis of the traditional incision of the petrous part of the temporal bone before the traditional sigmoid sinus. Finally, the scalp incision with a "C" shaped length of about 7cm after the ear was formed. The flap and the myofascial flap were opened forward, and the part of the mastoid process combined with the temporal craniotomy to form a pea shaped bone window of about 3.5cm x 3cm; open the anterior and temporal dura mater, ligation, cut off the upper sinus, and distraction the temporal and cerebellar hemispheres. Under the microscope, the anatomical structure was observed under the microscope.
Results: the posterior 7cm "C" scalp incision and the 3.5cm x 3cm size bone window can fully meet the exposure of the important structure. By adjusting the head and microscope angles, the anterior labyrinth keyhole approach of the sigmoid sinus can reveal the ipsilateral oculomotor nerve, the trochlear nerve, the trigeminal nerve, the facial nerve complex, the glossopharyngeal nerve, vagus nerve, and the post traffic. The artery, posterior cerebral artery, superior cerebellar artery, anterior inferior cerebellar artery, middle and upper part of the basilar artery, superior slope, lateral ventral surface of the pons, and posterior cavernous sinus.
Conclusion: the experimental design of the anterior labyrinthine keyhole approach is feasible and can reveal the above structure well. In theory, the keyhole approach can be used to carry out the ventral lateral tumor of the bridge brain, the cerebral cavernous angioma of the unilateral bridge, the limited upper diagonal meningioma, the acoustic neuroma of the inner ear canal, the upper middle artery in the basilar artery. Surgery, such as tumor.
The second part is neuronavigation assisted anatomic study of the anterior sigmoid sinus via labyrinthine keyhole approach.
Objective: to integrate the concept of minimally invasive keyhole surgery into the anterior approach of the sigmoid sinus, and to design the anterior trans sigmoid sinus via the labyrinth keyhole approach (including two surgical methods, including the partial labyrinth and the apex keyhole approach and the full labyrinthine keyhole approach) with the aid of neuronavigation, and to explore the feasibility of grinding the related bone structure in the approach to provide the basis for clinical application.
Methods: 8 adult cadavers were perfused with 4% formalin and perfusion of intracranial arteriovenous glue. The navigation data were established before the experiment. In the navigation system, the scope of the important structures such as the sigmoid sinus, the bone labyrinth and the inner ear canal were marked with different colors. The incision and bone window of the labyrinthine keyhole approach were used, the flap and the myofascial flap were opened in stratified forward, and the navigation was guided. The lower wheel profile of the sigmoid sinus, the semicircular canal of the bone, and the facial nerve canal, all the labyrinthine and the tip of the rock, all the labyrinthine, observe the difference of the exposed structure, measure the length of the exposed structure, the operation field of vision and the maximum angle of the operation field in the anterior space of the sigmoid sinus.
Results: 1, the incision of the labyrinth keyhole approach can fully meet the requirement of the labyrinthine keyhole approach.2. On the premise of pre operation planning, the neuronavigation can assist the precise completion of the sigmoid sinus, the contour of the semicircular canal, the part of the labyrinth and the tip of the rock, the upper inner canal nodules, and the grinding of all the fans, which can reduce the important structure caused by blind grinding. .3, compared with the labyrinthine keyhole approach, can obviously increase the slope, the exposure length of the cranial and abduction nerves, the horizontal and vertical horizons, the maximum field angle (P0.01).4 in the anterior space of the sigmoid sinus through partial labyrinthine and apex keyhole approach. The subdural structure shows the length of the subdural structure and the anterior intersigmoid sinus through the full labyrinth keyhole approach. The maximum gap angle was also significantly increased (all P0.01) than that of the labyrinthine keyhole approach, but the difference was not statistically significant (P0.05) compared with the partial labyrinth and the apex keyhole approach.
Conclusion: the anterior sigmoid sinus via the labyrinthine keyhole approach is feasible, and it can well reveal the diagonal area and meet the minimally invasive idea. The neuronavigation system can assist the precise completion of the bone structure grinding. Partial labyrinth, rock tip or full labyrinth grinding can improve the exposure of the diagonal area. The labyrinth and the rock tip keyhole approach can be widely exposed. In the oblique area, the cerebellopontine angle, the supratentorial area of the cerebellar cerebellum, the anterior region of the pontine and the posterior cavernous sinus, the structure of the III-XI brain nerve, and the possibility of retaining the hearing and facial nerve function is higher. The observation and operation of the full labyrinth keyhole approach are more, but the further increase of exposure is limited, and the hearing is sacrificed.
The third part is a quantitative study of neuronavigation assisted anterior petrosal keyhole approach to petroclival region.
Objective: with the aid of neuronavigation, the quantitative analysis of the differences in the exposure of the diagonal region by the four methods of the keyhole approach of the petrous bone before the sigmoid sinus and the petrous bone of the temporal bone is provided.
Methods: according to the sequence of the keyhole entry of the petrous sinus before the sigmoid sinus, it was divided into four surgical methods: the posterior labyrinth keyhole approach, the partial labyrinth and the apex keyhole approach, the total labyrinth keyhole approach and the cochlear keyhole approach. 6 (12 sides) were fixed with 4% formaldehyde and intracranial arteriovenous perfusion was perfused. The navigation data had been established. The human corpse was dissected by microdissection, and the keyhole approach was simulated in turn. Using the Stryker neuronavigation system, the exposed area of the diagonal area and the operation freedom degree were measured and analyzed statistically.
Results: 1, the exposed area of the rocky area of the four keyhole approaches was (93.1 + 17.6) mm2, (340.1 + 47.1) mm2, (357.4 + 56.4) mm2 and (377.5 + 59.4) mm2, and the post labyrinth keyhole approach was significantly smaller than the latter three (all P0.01), and there was no significant difference (all P0.05).2 in the subsequent three, and the operation freedom was in turn (555.1 + 164.1) mm2 and MM 2, (847.2 + 186.7) mm2 and (906.8 + 204.6) mm2, through partial labyrinth and apex, through all labyrinthine and three keyhole approach of cochlea were significantly higher than that of posterior locking keyhole approach (all P0.01). All labyrinthine and cochlear keyhole entry approaches were higher than those of partial labyrinthine and apex keyhole approach (all P0.01), but through all labyrinthine and cochlear keyhole approach, through all labyrinthine and cochlear keyhole approach There was no significant difference in partial labyrinth and petrous apex and total labyrinthine keyhole approach (P0.05).
Conclusion: the trauma of the four modes of operation increased in turn. The theory of the posterior labyrinth keyhole approach does not damage the hearing and facial nerve function, and its exposure to the diagonal area is relatively limited. The exposure to the partial labyrinth and the apex keyhole approach is more extensive, and the possibility of preserving the facial nerve function and hearing is higher. The lesions through the total labyrinth keyhole approach to the lesion The treatment is more convenient, but it can not further increase the exposure of the diagonal area. The approach of the cochlear keyhole approach can not further increase the exposure of the diagonal area, but it is suitable for the operation of the internal carotid artery invasion.
【学位授予单位】：苏州大学
【学位级别】：博士
【学位授予年份】：2007
【分类号】：R651;R322
本文编号：2125532
[Abstract]:Microsurgical anatomy of the approach of the retrosigmoid posterior keyhole approach
Objective: to follow the principle of minimally invasive surgery, integrate the concept of minimally invasive keyhole surgery into the anterior approach of the sigmoid sinus and explore the feasibility and surgical approach design of the posterior sigmoid labyrinthine keyhole operation, and observe the exposed anatomical structure to provide the basis for clinical application.
Methods: 8 cadaver cranial specimens were perfused with color emulsion by formalin fixation. According to the principle of "small and large enough", the skin incision was gradually reduced on the basis of the traditional incision of the petrous part of the temporal bone before the traditional sigmoid sinus. Finally, the scalp incision with a "C" shaped length of about 7cm after the ear was formed. The flap and the myofascial flap were opened forward, and the part of the mastoid process combined with the temporal craniotomy to form a pea shaped bone window of about 3.5cm x 3cm; open the anterior and temporal dura mater, ligation, cut off the upper sinus, and distraction the temporal and cerebellar hemispheres. Under the microscope, the anatomical structure was observed under the microscope.
Results: the posterior 7cm "C" scalp incision and the 3.5cm x 3cm size bone window can fully meet the exposure of the important structure. By adjusting the head and microscope angles, the anterior labyrinth keyhole approach of the sigmoid sinus can reveal the ipsilateral oculomotor nerve, the trochlear nerve, the trigeminal nerve, the facial nerve complex, the glossopharyngeal nerve, vagus nerve, and the post traffic. The artery, posterior cerebral artery, superior cerebellar artery, anterior inferior cerebellar artery, middle and upper part of the basilar artery, superior slope, lateral ventral surface of the pons, and posterior cavernous sinus.
Conclusion: the experimental design of the anterior labyrinthine keyhole approach is feasible and can reveal the above structure well. In theory, the keyhole approach can be used to carry out the ventral lateral tumor of the bridge brain, the cerebral cavernous angioma of the unilateral bridge, the limited upper diagonal meningioma, the acoustic neuroma of the inner ear canal, the upper middle artery in the basilar artery. Surgery, such as tumor.
The second part is neuronavigation assisted anatomic study of the anterior sigmoid sinus via labyrinthine keyhole approach.
Objective: to integrate the concept of minimally invasive keyhole surgery into the anterior approach of the sigmoid sinus, and to design the anterior trans sigmoid sinus via the labyrinth keyhole approach (including two surgical methods, including the partial labyrinth and the apex keyhole approach and the full labyrinthine keyhole approach) with the aid of neuronavigation, and to explore the feasibility of grinding the related bone structure in the approach to provide the basis for clinical application.
Methods: 8 adult cadavers were perfused with 4% formalin and perfusion of intracranial arteriovenous glue. The navigation data were established before the experiment. In the navigation system, the scope of the important structures such as the sigmoid sinus, the bone labyrinth and the inner ear canal were marked with different colors. The incision and bone window of the labyrinthine keyhole approach were used, the flap and the myofascial flap were opened in stratified forward, and the navigation was guided. The lower wheel profile of the sigmoid sinus, the semicircular canal of the bone, and the facial nerve canal, all the labyrinthine and the tip of the rock, all the labyrinthine, observe the difference of the exposed structure, measure the length of the exposed structure, the operation field of vision and the maximum angle of the operation field in the anterior space of the sigmoid sinus.
Results: 1, the incision of the labyrinth keyhole approach can fully meet the requirement of the labyrinthine keyhole approach.2. On the premise of pre operation planning, the neuronavigation can assist the precise completion of the sigmoid sinus, the contour of the semicircular canal, the part of the labyrinth and the tip of the rock, the upper inner canal nodules, and the grinding of all the fans, which can reduce the important structure caused by blind grinding. .3, compared with the labyrinthine keyhole approach, can obviously increase the slope, the exposure length of the cranial and abduction nerves, the horizontal and vertical horizons, the maximum field angle (P0.01).4 in the anterior space of the sigmoid sinus through partial labyrinthine and apex keyhole approach. The subdural structure shows the length of the subdural structure and the anterior intersigmoid sinus through the full labyrinth keyhole approach. The maximum gap angle was also significantly increased (all P0.01) than that of the labyrinthine keyhole approach, but the difference was not statistically significant (P0.05) compared with the partial labyrinth and the apex keyhole approach.
Conclusion: the anterior sigmoid sinus via the labyrinthine keyhole approach is feasible, and it can well reveal the diagonal area and meet the minimally invasive idea. The neuronavigation system can assist the precise completion of the bone structure grinding. Partial labyrinth, rock tip or full labyrinth grinding can improve the exposure of the diagonal area. The labyrinth and the rock tip keyhole approach can be widely exposed. In the oblique area, the cerebellopontine angle, the supratentorial area of the cerebellar cerebellum, the anterior region of the pontine and the posterior cavernous sinus, the structure of the III-XI brain nerve, and the possibility of retaining the hearing and facial nerve function is higher. The observation and operation of the full labyrinth keyhole approach are more, but the further increase of exposure is limited, and the hearing is sacrificed.
The third part is a quantitative study of neuronavigation assisted anterior petrosal keyhole approach to petroclival region.
Objective: with the aid of neuronavigation, the quantitative analysis of the differences in the exposure of the diagonal region by the four methods of the keyhole approach of the petrous bone before the sigmoid sinus and the petrous bone of the temporal bone is provided.
Methods: according to the sequence of the keyhole entry of the petrous sinus before the sigmoid sinus, it was divided into four surgical methods: the posterior labyrinth keyhole approach, the partial labyrinth and the apex keyhole approach, the total labyrinth keyhole approach and the cochlear keyhole approach. 6 (12 sides) were fixed with 4% formaldehyde and intracranial arteriovenous perfusion was perfused. The navigation data had been established. The human corpse was dissected by microdissection, and the keyhole approach was simulated in turn. Using the Stryker neuronavigation system, the exposed area of the diagonal area and the operation freedom degree were measured and analyzed statistically.
Results: 1, the exposed area of the rocky area of the four keyhole approaches was (93.1 + 17.6) mm2, (340.1 + 47.1) mm2, (357.4 + 56.4) mm2 and (377.5 + 59.4) mm2, and the post labyrinth keyhole approach was significantly smaller than the latter three (all P0.01), and there was no significant difference (all P0.05).2 in the subsequent three, and the operation freedom was in turn (555.1 + 164.1) mm2 and MM 2, (847.2 + 186.7) mm2 and (906.8 + 204.6) mm2, through partial labyrinth and apex, through all labyrinthine and three keyhole approach of cochlea were significantly higher than that of posterior locking keyhole approach (all P0.01). All labyrinthine and cochlear keyhole entry approaches were higher than those of partial labyrinthine and apex keyhole approach (all P0.01), but through all labyrinthine and cochlear keyhole approach, through all labyrinthine and cochlear keyhole approach There was no significant difference in partial labyrinth and petrous apex and total labyrinthine keyhole approach (P0.05).
Conclusion: the trauma of the four modes of operation increased in turn. The theory of the posterior labyrinth keyhole approach does not damage the hearing and facial nerve function, and its exposure to the diagonal area is relatively limited. The exposure to the partial labyrinth and the apex keyhole approach is more extensive, and the possibility of preserving the facial nerve function and hearing is higher. The lesions through the total labyrinth keyhole approach to the lesion The treatment is more convenient, but it can not further increase the exposure of the diagonal area. The approach of the cochlear keyhole approach can not further increase the exposure of the diagonal area, but it is suitable for the operation of the internal carotid artery invasion.
【学位授予单位】：苏州大学
【学位级别】：博士
【学位授予年份】：2007
【分类号】：R651;R322
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