【作者】 王嵩；

【导师】 李牧；

【作者基本信息】 天津医科大学 ， 外科学， 2012， 硕士

【摘要】 [目的]通过熟悉内镜下经鼻入路至颅底中线区,包括前颅底、鞍区、中颅底、斜坡、寰枕交界区及后颅底的内镜解剖结构特点,探索神经内镜下经鼻入路显露颅底中线区的可行性,并进一步研究该手术入路的适应证、手术技巧及手术并发症的防治。[方法]选用新鲜尸头40具,用红色乳胶灌注动脉,蓝色乳胶灌注静脉系统后,75%酒精浸泡5天备用。分别运用直径4mmm,长度18cm的0°和30°硬质内镜(蛇牌,德国),在神经导航系统(史塞克,美国)的引导下模拟手术过程,经单及双侧鼻腔采用经鼻入路对尸头进行颅底中线区内镜下解剖。观察内镜下颅底可暴露的范围和解剖结构,并定量测量各个解剖标志之间的距离。[结果]手术入路过程中鼻腔阶段主要的解剖标志是：下鼻甲、中鼻甲、上鼻甲、鼻中隔、后鼻孔、蝶筛隐窝和蝶窦开口；颅底阶段的主要解剖标志是：鞍底、鞍结节、蝶骨平台、前筛动脉、后筛动脉和筛板、颈内动脉隆起、视神经管隆起、颈内动脉-视神经隐窝、斜坡隐窝、翼管、咽鼓管和枕髁等。尸头标本上测量两眶内侧壁的最宽距离为34.7±3.5mm,前后筛动脉在眶内侧壁的距离为17.1±2.8mm,蝶窦开口距后鼻孔为15.6±3.5mmm,两侧蝶窦开口之间的距离13.2±2.3mm,两侧颈内动脉-视神经隐窝内侧距离为15.3±1.2mm,蝶鞍横径为19.8±3.9mm,蝶鞍前后径为9.1±1.5mm,蝶窦底部至斜坡隐窝下缘的距离为16.2±3.7mm,斜坡段两侧颈内动脉的距离为16.8±3.5mm,枕骨大孔前缘至鞍背的距离39.6±4.3mm。[结论]神经内镜经鼻入路可暴露前颅底、中颅底及后颅底中线区的骨性及硬膜下解剖结构,并可以提供宽广、清晰的手术视野,是处理颅底中线区病变的一种新的微侵袭方法。通过模拟内镜手术过程对尸头进行解剖,可以熟练掌握内镜手术技术和经鼻入路内镜解剖知识,为临床开展内镜经鼻入路颅底手术提供可靠保障。更多还原

【Abstract】 Objective:The aim of study was to understand the endoscopic anatomical landmarks and the extent of exposure to the midline skull base by endoscopic endonasal approach, and to discuss the feasibility of exposing the midline skull base, the indication of the approach and prevention of complications.Methods:Forty fresh adult cadaver heads whose arterial and ventracal system was injected with latex and keeped in75%alchol for5days. Endoscopic endonasial dissections were performed using a rigid endoscope ((AESCULAP, Germany) with4mm indiameter,18cm in length, and equipped with0°,30°and45°lenses. An extended endoscopic endonasal approach to the midline skull base was made through two nostrils in all cases to measure the distance between main anatomical landmarks and area of exposure.Results:During the step in nasal, the detailed endoscopic anatomy consisted of the inferiorturbinate, the middle turbinate, superior turbinate, nasal septum, choana, speno-ethmoidrecess and the sphenoidal ostium. During the step involve the clivus, the endoscopic anatomy landmark was composed of the sellae floor, tuberculum sellae, sphenoidal planum, anterior ethmoidal cell, posterior ethmoidal cell, clivus recess, optic-carotid recess, optic protuberance, carotid protuberance. The mean maximum distance between the two medial orbital walls was34.7±3.5mm, The the anterior and posterior ethmoidal arteries was17.1±2.8mm, The distance between bilateral optic-carotid recess was15.3±2.2mm, the width of sallae was19.8±3.9mm, between anterior and posterior margin was9.1±1.5mm, the distance from sellae to the anterior margin of foramen magnum was39.6±4.3mm, from sallae to clivus recess was16.2±3.7mm, the distance between the two crotid arterys in the clivus was16.8±3.5mm.Conclusions:The endoscopic endonasal approach could export the anterior, medial and posterior skull base, and provide wide and clear operative field, it is a minimally invasive technique to approach the midline skull base. Adequate endoscopic skill and ample endoscopic anatomy were required for clinical application of this approach.更多还原