眶部经颅手术入路显微解剖学研究

发布时间：2018-11-17 08:47

【摘要】： 单纯眼眶内的肿瘤，眼科医生主要通过前路入眶和外侧开眶切除肿瘤。但是对于眶内后侧、肌锥、眶尖、视神经管肿瘤、颅眶沟通性肿瘤，常规开眶方法暴露效果较差。近年来，随着神经外科影像学和颅底显微外科的发展，经颅入路处理眶深部病灶趋向广泛。经颅手术为部分眶内肿瘤和颅-眶沟通性肿瘤患者提供了合适的治疗方法。根据肿瘤大小、占据眶内的部位以及是否有颅内侵犯，精心设计开颅和开眶骨瓣，可使肿瘤得到最佳显露；而熟悉眶内解剖并熟练运用显微外科技术是提高全切除率、减少并发症的关键。本文通过对经颅入眶手术入路的显微解剖学研究，为临床提供显微解剖依据。目的为眶部经颅手术入路提供详细的显微解剖学依据和解剖学参数，分析经颅手术入路的优势及其易损伤结构。材料和方法成年国人尸头15例(30侧)，经10％的福尔马林液充分固定。经额手术入路，采用显微解剖技术观察与手术入路有关的解剖标志，，观测开眶后眶内结构在不同手术视野下的位置、毗邻、走行、分布等，获取重要的解剖学参数，以指导临床和手术操作，避免出现严重手术并发症，并应用SPSS10.0统计软件进行数据分析。结果内侧入路是经上斜肌与提上睑肌之间的间隙，经此入路可切除眶尖区内侧病变，暴露从球后到视神经管之间的视神经。滑车神经、眼动脉、鼻睫神经和眼上静脉分别跨过视神经至眶内侧部，它们跨过视神经的内侧点至视神经眶口内侧点的距离分别为5.00±1.37mm、9.27±2.04mm、10.66±1.98mm和19.33±1.59mm；中央入路是经提上睑肌与上直肌之间的间隙，根据额神经牵向内侧还是牵向外侧分为两种术式，经此入路可行眶内视神经中段病变的切除；外侧入路是经上直肌和外直肌之间的间隙，根据眼上静脉牵向内侧还是外侧也分为两种术式，可切除眶尖区上、下、外侧部及眶上裂区病变，滑车神经、眼动脉、鼻睫神经和眼上静脉分别由外侧跨过视神经至眶内侧部，它们跨过视神经的外侧点至视神经眶口外侧点距离分别为2.76±0.63mm、10.50±2.28mm、9.34±1.96和19.55±2.13mm，眼上静脉限制了对眶尖深部的显露，其穿过眶上裂的外侧缘至眶上裂外侧缘之间的距离为2.73±0.52mm。结论对于眶内肿瘤应根据病变在眶内的具体位置选择相应的最佳手术入路，这样有助于克服盲目的破坏性手术，本实验为眶部经颅手术提供了必要的显微解剖学依据，以避免损伤重要的神经血管结构。
[Abstract]:Simple orbital tumors, ophthalmologists mainly through the anterior approach to the orbit and lateral orbital resection of tumors. But for the posterior orbital, muscle cone, orbital apex, optic canal tumor, cranio-orbital communication tumor, the conventional method of orbital exposure is poor. In recent years, with the development of neurosurgery imaging and skull base microsurgery, transcranial approach to the treatment of deep orbital lesions tend to be extensive. Transcranial surgery provides a suitable treatment for some orbital tumors and cranio-orbital tumors. According to the size of the tumor, the location of the orbit and whether there are intracranial invasion, carefully designed craniotomy and orbital bone flap can make the tumor the best exposure; The key to increase the rate of total excision and reduce complications is to be familiar with intraorbital anatomy and use microsurgery skillfully. The microanatomy of transcranial orbital approach is studied in order to provide the basis for clinical microanatomy. Objective to provide detailed microanatomical basis and anatomical parameters for transcranial orbital approach, and to analyze the advantages and vulnerable structure of transcranial approach. Materials and methods Fifteen cadaveric heads (30 sides) of adult Chinese were fully fixed with 10% formalin solution. The anatomical markers related to the surgical approach were observed by microdissection technique, and the position, proximity, movement and distribution of the orbital structure after orbital opening were observed in different surgical fields, and the important anatomical parameters were obtained. In order to guide clinical and surgical operation, to avoid serious surgical complications, and to use SPSS10.0 statistical software for data analysis. Results the medial approach was the space between the superior oblique muscle and the levator palpebral muscle. The medial lesion of the orbital apical region could be excised through this approach and the optic nerve from the posterior bulb to the optic canal could be exposed. The trochlear nerve, the ophthalmic artery, the nasociliary nerve and the superior ophthalmic vein crossed the optic nerve from the medial point of the optic nerve to the medial point of the orbital orifice of the optic nerve, and the distance between them was 5.00 卤1.37 mm and 9.27 卤2.04mm, respectively. 10.66 卤1.98mm and 19.33 卤1.59mm; The central approach is the space between the levator palpebral muscle and the superior rectus muscle, which is divided into two types according to the medial or lateral traction of the frontal nerve. The lateral approach is the space between the superior rectus muscle and the outer rectus muscle. According to the medial or lateral superior ophthalmic vein traction, the lateral approach can also be divided into two types of operations: superior, inferior, lateral and supraorbital fissure lesions, trochlear nerve, ophthalmic artery. The distance between the lateral point of the optic nerve and the lateral point of the orbital orifice was 2.76 卤0.63 mm, 10.50 卤2.28 mm, 9.34 卤1.96 and 19.55 卤2.13 mm, respectively, between the nasociliary nerve and the superior ophthalmic vein, and the distance from the lateral point of the optic nerve to the lateral point of the orbital orifice of the optic nerve was 2.76 卤0.63 mm and 19.55 卤2.13 mm respectively. The distance between the lateral margin of the supraorbital fissure and the lateral margin of the supraorbital fissure is 2.73 卤0.52 mm. Conclusion the optimal operative approach should be selected according to the specific location of the lesions in the orbit, which is helpful to overcome the blind destructive surgery. This experiment provides the necessary microanatomical basis for the transcranial orbital surgery. To avoid damage to important neurovascular structures.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2007
【分类号】：R322

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