【作者】 秦军；

【导师】 雷霆；

【作者基本信息】 华中科技大学 ， 外科学， 2007， 博士

【摘要】 第一部分:内镜下经鼻腔蝶窦入路的手术解剖学研究目的:通过对经鼻蝶入路至鞍区的内镜解剖研究,为内镜下经鼻蝶入路鞍区手术提供解剖学参数和形态学依据。方法:测量40例成人颅骨干标本的解剖数据,10例福尔马林固定的成人尸头模拟经鼻蝶手术入路,内镜下进行解剖观察。结果:蝶窦口与鼻底夹角(31.80±5.20 )o。蝶窦口直径(11.0±1.70)mm,其中心距鼻前棘、正中线、蝶鞍前壁、视神经隆突、颈内动脉隆突之间的距离分别为(55.00±4.50)mm、(3.00±2.20)mm、(16.00±3.50)mm、(11.00±2.30)mm、(13.50±2.00)mm;视神经管和颈内动脉隆起在蝶窦外侧上隆起率分别为30 %和70 %。鞍底中线距视神经管隆起、颈内动脉管隆起、鞍隔、视交叉、海绵窦内颈内动脉、海绵窦内动眼神经、海绵窦内滑车神经、海绵窦内外展神经之间的距离分别为(5.67±1.53 ) mm、(5.39±1.38 ) mm、(9.97±1.42 ) mm、(14.96±1.91)mm、(11.05±1.99)mm、(13.81±1.82)mm、(15.15±1.53)mm、(12.70±1.63 )mm。内镜下经鼻-蝶窦入路可清晰显露蝶窦开口,在蝶窦内可显示蝶窦内的隐窝及视神经、颈内动脉的骨性隆起及鞍底骨质。打开鞍底骨质可见鞍底硬脑膜,向后延续为斜坡硬膜,两侧可见海绵窦内侧壁。切开鞍底硬膜可见垂体,鞍隔以上,能清晰显示第三脑室底、视神经、视交叉及鞍旁结构等。结论:内镜下经鼻蝶手术入路可清晰地显露蝶窦口,蝶窦内及蝶鞍周围的解剖结构,适用于鞍内、鞍旁、鞍上病变的手术治疗。第二部分:经鼻蝶入路至斜坡区的内镜解剖学研究目的通过对经鼻蝶入路至斜坡区的内镜解剖研究,为临床提供解剖学参数和形态学依据。方法测量40例成人颅骨干标本的解剖数据,10例福尔马林固定的成人尸头模拟经鼻蝶手术入路,用内镜对斜坡区进行解剖观察。结果前鼻棘至蝶窦口、鞍底、鞍结节中心、鞍背中心、颈动脉管、视神经管颅口和枕骨大孔前端的距离分别为(55.62±4.23)mm、(71.50±6.21)、(79.02±4.97 )mm、(81.04±8.02 )mm、(68.39±6.42 )mm、(67.96±6.45)mm、( 91.08±5.20)mm;以鼻腔底平面为基线,与上述结构之间矢状面夹角分别为(32.09±3.90 )o、(31.34±6.02 )o、(35.02±4.03 )o、(34.65±3.23 )o、(32.01±3.02 )o、(36.55±5.20 )o、(39.04±8.02 )o ;卵圆孔、破裂孔、颈动脉管外口、舌下神经管外口内侧缘距正中线的距离分别为( 23.30±1.97 )mm、( 10.56±2.39 )mm、( 25.07±2.77 )mm、( 16.98±1.99 )mm。斜坡的长、高、分别为(32.43±5.46 )mm、(35.01±4.12 )mm ;上、中、下部的厚度分别为(17.23±3.12 )mm、(9.96±3.10 )mm、(6.35±2.95)mm。枕骨大孔前后径(31.4±13.3)mm ,枕骨大孔左右径(28.8±2.4)m m,枕骨大孔前缘的厚度为(3.8±0.4)mm。经鼻蝶入路至斜坡区在内镜下硬膜外可显露从鞍底到斜坡、枕骨大孔的中线附近结构。在硬膜下可显露基底动脉分叉、动眼神经、脑干腹侧等结构。结论内镜下行经蝶入路可以通过良好的视角显露鞍后-斜坡解剖结构,适用于鞍后-斜坡区病变的手术治疗。第三部分:内镜下经鼻腔-蝶窦入路治疗鞍区、斜坡区病变的临床研究目的实施内镜下经鼻腔-蝶窦入路治疗鞍区、斜坡区病变,探讨神经内镜在术中的临床应用价值。方法采用内镜辅助经鼻腔-蝶窦手术入路切除16例垂体瘤;内镜下经单鼻腔-蝶窦入路治疗垂体瘤35例,脑脊液鼻漏2例;斜坡脊索瘤2例。结果内镜辅助经单鼻孔-蝶窦入路对蝶窦、鞍区等结构显露良好,内镜可弥补显微镜的盲区。内镜辅助经单鼻腔-蝶窦入路手术全切13例,近全切3例;内镜下经单鼻腔-蝶窦入路治疗垂体瘤35例,手术全切30例,近全切5例;脑脊液鼻漏修补2例,效果良好;斜坡脊索瘤2例,手术全切1例,近全切1例;55例病人中17例出现一过性尿崩,5例出现一过性脑脊液鼻漏,3例出现视力恶化,经治疗后好转。术后无鼻中隔穿孔及其它相关严重并发症和手术死亡。结论临床应用结果表明内镜下行经单鼻孔-蝶窦入路治疗鞍区、斜坡区病变微创、安全、疗效确切;采用内镜技术与显微外科技术相结合在经鼻腔一蝶窦入路手术中切除术中具有优势互补的作用,有利于实现微创手术的目的并可提高手术疗效。更多还原

【Abstract】 PartⅠAnatomical Study of Endoscopic Operation via the Transsphenoid Sinus ApproachObjective The endoscopic surgical study of the sphenoid sinus and sellar area via transsphenoidal approach was studied to establish an anatomic basis for surgical treatment . Methods 40 dry adult skulls were used to observe and measure , simulated surgical was performed on 10 adult cadaver head and some anatomic details were observed by endoscopy . Results Average distance between the anterior nasal spina to ostia of sphenoidal sinus was 55.00±4.50mm, The distance from central line to ostia of sphenoidal sinus was 3.00±2.20mm, the angle between sphenoid ostia and nasal base was 31.80±5.20o . The distances from sphenoid ostia to the anterior wall of sella was 16.00±3.50 mm, to optic strut was 11.00±2.30mm, to internal carotid eminence was 13.50±2.00 mm. 30% of optical nerve canal and 70% of internal carotid bugle on the area of lateral sphenoid sinus . The distances from midline of cellar floor to optic strut was 5.67±1.53mm, to internal carotid eminence was 5.39±1.38mm,to diaphragm was 9.97±1.42mm, to optic chiasm was 14.96±1.91mm, to internal carotid artery was 11.05±1.99mm, to oculomotor nerve was 13.81±1.82mm, to trochlear nerve was 15.15±1.53mm and to abducens nerve was 12.70±1.63mm respectively. By transsphenoidal approach ostia of sphenoidal sinus was exposed cleanly. In sphenoidal sinus optical nerve and internal carotid eminence bony of sellar floor were exposed. After removal of bony of sellar floor such anatomic structures such as dura of cellar floor, dura of clivus and medial wall of cavernous sinus were exposed. after removal of dura of sellar floor and sellar diaphragm, optic nerve,chiasm,pituilary bland, and hypothalamus were exposed. Conclusion: The anatomic structures of ostia of sphenoidal, sinus sellar and parasellar regions can be clearly through the transnaso-sphenoidal approach which is available to surgery for lesions located in parasellar and supersellar regions.PartⅡThe Endoscopic Anatomic Study via the Transsphenoidal Approach to the ClivusObjective The endoscopic surgical study of the clivus via the transsphenoidal approach was studied to establish an anatomic basis for surgical treatment . Methods 40 dry adult skulls were used to observe and measure , simulated surgical was performed on 10 adult cadaver head and some anatomic details were observed by endoscopy . Results Average distance between the anterior nasal spina to ostia of sphenoidal sinus , tuberculum sellae , root of sellar area , dorsum sellae , cranial entrance of internal carotid artery and optic canal , anterior part of great occipital foramen were 55.62±4.23mm, 71.50±6.21, 79.02±4.97 mm, 81.04±8.02 mm, 68.39±6.42 mm, 67.96±6.45 mm, 91.08±5.20mm respectively . The angle between root of nasal cavity and those structures were 32.09±3.90 o, 31.34±6.02o , 35.02±4.03o , 34.65±3.23o , 32.01±3.02o, 36.55±5.20o, 39.04±8.02 o respectively. The distance from central line to inner border of oval foramen, to lacerated foramen , to outer entrance of carotid canal and to inner border of outer entrance of hypoglossal canal were 23.30±1.97 mm ,10.56±2.39 mm , 25.07±2.77 mm , 16.98±1.99 mm respectively. The length and height of clivus were 32.43±5.46 mm ,35.01±4.12 mm. and the thickness of upper , middle and lower part were 17.23±3.12 mm、9.96±3.10mm、6.35±2.95mm respectively . the thickness of anterior part of great occipital foramen(3. 8±0. 4)mm. extradural structures such as root of sellar area , clivus , great occipital foramen ; Intradural structures such as basal artery bifurcation ,posterior cerebral artery ,oculomotor nerve ,can also be exposted under transsphenoidal approach by endoscopy to clivus. Conclusions Endoscopic transsphenoidal approach can well expose easily reach the area of central skull base . This finding provide a rational surgical approach for operation from transsphenoidal to clivus by endoscopicy. PartⅢClinical Study on Endoscopic Endonasal Transsphenoidal Surgery for Diseases of the Sellar and ClivusObjective To evaluate the possibility and gain surgical experiences on endoscopic endonasal transsphenoidal surgery for diseases of the sellar and the clivus. Methods Sixteen cases of pituitary adenomas were proformed transsphenoidal microsurgery under the assistance of nasal endoscope, 35 cases of pituitary adenomas , 2 cases cerebrospinal rhinorrhea, 2 cases chordoma invading the sphenoid bone and clivus were treated by neuroendoscopic techniques . Results The structures of the sphenoid sinus and sellar regions can be exposed clearly by this approach . The blind area of microscope may be showed through endoscope .of 16 patients underwent the assistance of nasal endoscope ,Tumor was totally removed in 13 cases ,subtotally removed in 3 cases. Of 35 patients underwent endoscopic endonasal transsphenoidal surgery with pituitary adenomas, 30 underwent total resection of the tumor and 5 subtotal resection, 2 cases cerebrospinal rhinorrhea were cured . Of 2 cases chordoma invading the sphenoid bone and clivus ,1 underwent total resection of the tumor and 1 subtotal resection, The complication included transient diabetes insipidus in 17 patients, transient cerebrospinal rhinorrhea in 5 patients,and transient visual deterioration in 3 patients ,There was no severe complication and no operative death .Conclusions The clinical study showed that endoscopic endonasal transsphenoidal surgery is a safe and effective method of treatment of the patients with diseases of the sellar and the clivus. That microsurgical technique combined with nasal endoscope had dual advantages and gained minimally invasive effects in the operation of endonasal transsphenoidal surger. endoscope-assisted microneurosurgery can improve the quality of neurosurgery.更多还原