神经内窥镜下经鼻—蝶窦鞍区肿瘤切除术的解剖学研究

发布时间：2018-12-05 21:29

【摘要】： 本论文的研究目的:是通过对鞍区断层解剖和神经内窥镜下经鼻-蝶窦外科入路解剖的比较研究,了解鞍区区域内重要的解剖定位标志和特点,临床上神经内窥镜下经鼻-蝶窦鞍区肿瘤切除术会有损伤颈内动脉和海绵窦引起致命性出血以及损伤视神经或视交叉导致失明等严重并发症发生的可能,为避免这些并发症的发生,除了提高设备水平外,熟练掌握神经内窥镜下经鼻-蝶窦入路解剖具有非常重要的意义。虽然神经内窥镜下经鼻-蝶窦鞍区肿瘤切除术表现出优异的特性,但也存在着一些缺点,它所提供的是二维图像,缺乏立体感。鞍区局部组织断层解剖则提供了该部位的连续切片资料,帮助手术者建立鞍区立体解剖观念,了解鞍区重要结构的三维解剖关系,对临床经鼻-蝶窦入路鞍区肿瘤切除术具有指导作用。为提高经鼻-蝶窦入路切除鞍区肿瘤的手术成功率和安全性提供解剖学依据。方法:第一部分:取用经福尔马林固定后的成人12例尸头鞍区部为实验材料,步骤:①标本脱钙:所用材料用10%盐酸浸泡12～20d,直至骨组织可用针刺入时为止;②冲洗:取出标本,用循环水冲洗24h;③常规脱水:将标本逐级脱水,直到标本变硬为止;④浸胶:将脱水后的标本块先浸入5%火棉胶中,在真空干燥箱内以66kPa的压力抽真空30min,静置1天后,再抽真空,再静置1天后浸入8%火棉胶中;以同样条件抽真空2次。⑤包埋与制块:用15%火棉胶作为包埋剂,包埋块的形成约15～30d。将包埋块置入70%酒精中硬化保存;⑥焊块与切片:采用德国酒浸L型切片机制备切片,对标本进行连续切片,切片厚度设置在0.5～1.0mm。第二部分:采用成人尸体头颅标本6例,均经10%福尔马林溶液固定。神经内窥镜下模拟经鼻-蝶窦手术入路,使用KARL STORZ神经内窥镜系统观察鼻腔、蝶窦、颅内鞍区解剖学形态。记录并了解手术区域中特别是蝶鞍及周围结构的解剖形态,发现一些与手术相关的重要标志性结构,并予以测量和分析。结果:①海绵窦是一个充满血液的静脉通道,分为前下、后上、内侧和外侧4个主要间隙。其中海绵窦后上间隙最大,海绵窦外侧间隙最小。同时,在海绵窦内仍可见少量静脉存在。②海绵窦外侧壁可分为浅、深两层。浅层即硬脑膜层,较为致密。深层为疏松结缔组织,有动眼神经、滑车神经、眼神经和上颌神经穿行其中。此外,有77.28%的标本在海绵窦外侧壁两层之间存在静脉窦;③海绵窦面积等指标在冠状切片由前向后逐渐增大,以垂体前叶中部或垂体柄层面为最大,而后逐渐减小;④蝶窦口是最重要的定位标志,蝶窦开口位于上鼻甲后上方的蝶筛隐窝,蝶筛隐窝虽然是恒定存在的结构,但形态变异很大,因而不能作为非常可靠的定位解剖标志;⑤蝶窦中隔多数不在中线而偏于一侧,且多偏于左侧,故蝶窦中隔不能作为经鼻-蝶窦入路鞍区肿瘤切除术定中线的标志;⑥初步证实蝶鞍一侧或两侧的缺失区或薄弱区可以作为鞍区肿瘤从鞍区至鞍旁区发展的通道,海绵窦内侧壁薄弱甚至缺如是垂体腺瘤侵犯海绵窦的解剖学基础。结论:鞍区局部组织火棉胶包埋法的连续断层切片提供了该部位的连续切片解剖资料,对临床经鼻-蝶窦入路鞍区肿瘤切除术具有指导作用。经鼻-蝶窦入路时神经内窥镜可以提供一个全景的术野,可较好地显露蝶窦、鞍区颅底区域。内窥镜下经鼻-蝶窦入路从解剖学角度可以处理大部分以往必须经颅手术的鞍区病变。此入路的优点是不开颅,避免了牵拉脑组织和对神经、血管等结构的手术副损伤。对于手术中保护重要神经、血管结构意义重大。
[Abstract]:The purpose of this paper is to study the important anatomical location markers and features in the area of the saddle area by a comparative study of the anatomy of the sellar area and the transnasal-butterfly surgical approach in the area of the saddle area. In the clinical neuroendoscope, the resection of the nasal-butterfly saddle area can damage the fatal bleeding caused by the internal carotid artery and the sponge, and the occurrence of serious complications such as blindness caused by the injury of the optic nerve or the visual cross can be avoided, so as to avoid the occurrence of the complications, besides the improvement of the equipment level, It is of great significance to master the anatomy of the transsphenoidal approach under the neuroendoscope. Although the resection of the nasal-butterfly saddle area under the neuroendoscope shows excellent characteristics, there are some disadvantages, which provide two-dimensional images and lack of three-dimensional effect. The anatomy of the local tissue of the saddle area provides the continuous slice data of the part, which can help the operator to set up the three-dimensional anatomical concept of the saddle area, and to know the three-dimensional anatomical relation of the important structure of the saddle area, and has the guiding function for the clinical transsphenoidal approach to the tumor resection of the saddle area. In order to improve the surgical success rate and safety of the transsphenoidal approach to the removal of the tumor of the saddle area, the anatomical basis is provided. Methods: The first part: 12 cases of adult cadaver head with formalin fixation were used as the experimental material. The following steps were as follows: the material used for removing calcium: the used material was soaked in 10% hydrochloric acid for 12-20d until the bone tissue can be used for acupuncture, and then rinse: take out the specimen and wash the specimen with the circulating water for 24h; the method comprises the following steps of: carrying out conventional dehydration on the specimen until the specimen is hardened; soaking the specimen until the specimen is hard; soaking the dehydrated specimen in a 5% collodion, pumping for 30min in a vacuum drying oven at a pressure of 66kPa, standing for 1 day, vacuum-pumping, standing for 1 day, and then soaking in 8% of the collodion; the vacuum was evacuated twice under the same conditions. the embedding and the making of the block: 15% of the collodion is used as the embedding agent, and the embedding block is formed in the form of about 15 to 30d. The embedded block was put into 70% alcohol to be hardened and stored; the welding block and the slice: the section was prepared by using the German wine-immersed L-type microtome, and the specimen was continuously sectioned, and the thickness of the section was set to 0.5 ~ 1.0mm. The second part: 6 cases of head specimens of adult cadavers were fixed by 10% formalin. The anatomy of the nasal cavity, the butterfly valve and the intracranial saddle area was observed by using the KARL STORZ neuroendoscope system. The anatomy of the surgical area, in particular the sella and the surrounding structure, was recorded and understood, and some important landmark structures associated with the procedure were identified and measured and analyzed. Results: The sponge sponge is a venous channel filled with blood, divided into four main gaps, namely, front, back, medial and lateral. wherein the gap between the sponge and the sponge is the largest, and the clearance of the outer side of the sponge is the smallest. At the same time, a small number of veins were still visible in the sponge. The outer side wall of the sponge sponge can be divided into a shallow and a deep layer. The superficial layer, the dura mater, is relatively dense. The deep layer is loose connective tissue, with a moving-eye nerve, a sliding vehicle nerve, a eye and a maxillary nerve. In addition, 77. 28% of the specimens had a venous connection between the two layers of the outer side wall of the sponge; the index of the area of the sponge and the sponge gradually increased from the front to the back in the coronal section, at the middle of the anterior lobe of the pituitary or the pituitary stalk, and then gradually decreased; the first butterfly port was the most important positioning mark, the sphenoidal opening is located above the upper part of the upper part of the upper part of the upper part of the upper part of the upper part of the upper part of the upper part of the upper part of the butterfly screen, Therefore, the septum of the butterfly valve can not be used as a marker of the midline of the tumor resection in the saddle area through the nasal-butterfly approach, and the defect area or the weak area on one side or both sides of the sella can be preliminarily confirmed as a channel that can be developed from the saddle area to the saddle side area as a saddle area tumor, The inner side wall of the sponge is weak or even absent, such as the anatomical basis of the pituitary adenoma invading the sponge. Conclusion: The continuous slice section of the local tissue fire-tissue embedding method in the saddle area provides the continuous slice anatomical data of the site, and has a guiding role in the clinical transsphenoidal approach to the tumor resection of the saddle area. Through the nasal-butterfly approach, the neuroendoscope can provide a panoramic field of operation, which can better reveal the area of the skull base of the butterfly and the saddle area. The endoscopic transsphenoidal approach can be used to deal with most of the disease of the saddle area that has to be undergone the operation of the cranium. The method has the advantages of no craniotomy, and avoids the operation of pulling the brain tissue and the operation of the structures such as the nerves, the blood vessels and the like. The vascular structure is of great significance for the protection of important nerves in the operation.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2008
【分类号】：R322.8-3;R730.5

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