目的 研究扩大的内镜下经鼻至斜坡区手术入路的解剖要点及其位置关系。方法 防腐尸头标本10例,显微镜下解剖观察扩大的经鼻至斜坡区手术入路的解剖结构。新鲜尸头标本5例,模拟扩大的内镜经鼻入路斜坡手术。另外,对2例侵犯斜坡区的病例,采用扩大的内镜下经单鼻孔手术入路,结合影像检查资料,观察肿瘤影像解剖结构及切除情况。结果 扩大的内镜经鼻至斜坡区中线部位主要标志点由前至后依次为中鼻甲、后鼻孔、咽鼓管咽口、鼻咽部黏膜、双侧蝶窦口、头长肌和颈长肌、咽结节、枕骨大孔前缘中点等结构。手术中斜坡能够磨除的最大范围(分别以两侧颅内翼管和破裂孔为界,各自距中线最短距离):翼管左侧(9.25±0.26)mm,右侧(9.19±0.27)mm;破裂孔左侧(10.64±0.43)mm和右侧(10.75±0.51)mm。内镜下完全模拟手术操作表明,内镜经鼻入路可充分显露颅颈交界区及斜坡的解剖结构,完全达到真实内镜下操作要求。2例肿瘤全切,术中、术后未发现严重手术并发症。结论 采用扩大的单纯内镜经鼻入路可更直接到达斜坡区,并可安全切除肿瘤,避免损伤重要的神经血管和脑组织。
Abstract
Objective To study the key anatomical landmarks and the relationship used in surgical approach from nasal cavity to ventral slope by extended endoscopy. Combined with 2 cases of sellar tumors, the clinical application of the surgical approach in ventral slope was explored. Methods Ten formalin-fixed specimens of head were used to observe the key anatomical landmarks from nasal cavity to ventral slope with anatomical microscope, and established surgical mark. Five fresh specimens of head were used to do along the endoscopic nasal approach. Two cases of tumor invasion slope were used to observe anatomical characteristics of tumor and surgical results by expanded endonasal endoscopic and image data.Results Marking points in the middle line of surgical approach from nasal cavity to ventral slope were as follows: the middle turbinate, choanal , pharyngeal mouth, nasopharynx mucosa , bilateral sphenoid mouth, head length and longus muscle , pharyngeal tubercle , the midpoint of the leading edge of the foramen magnum and so on. To expose the ventral region of middle-lower part of clivus completely, the ranges of stripping the inferior wall of sphenoid sinus and the lower clivus were bounded by pterygoid canal and foramen lacerum, and the distances from the median line were(9.25±0.26)mm and(9.19±0.27)mm, respectively. Simulating surgeries under endoscopy proved the facticity was equal to the real operation. The tumor in 2 cases was completely removed without serious complications after postoperative and follow-up period.Conclusions Extended endoscopic nasal approach can directly reach the clivus, remove tumor safely and keep away the important neurovascular structures and avoid traction of brain.
关键词
内镜 /
经鼻入路 /
斜坡 /
解剖学
Key words
endoscope /
endonasal approach /
clivus /
anatomy
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参考文献
[1] 廖建春,刘海斌,邓彬华,等. 翼腭窝区域的影像学解剖研究及其临床意义[J].中国临床解剖学杂志,2013,31(6):627-630.
[2] 刘环海,廖建春,范静平,等. 内镜下扩大经蝶术中蝶窦后壁的应用解剖[J].第二军医大学学报,2011,32(1):25-27.
[3] Romero F R, Listik S . Endoscopic endonasal approach for clival chordomas-case report and review of literature[J]. Bras Neurocirurg,2012,23 (1): 61-64.
[4] 张秋航.内镜颅底外科的发展[J].中国微侵袭神经外科杂志,2014,19(1):1-4.
[5] Jacquesson T,Berhouma M,Tringali S,et al.Which Routes for Petroclival Tumors? a Comparison Between the Anterior Expanded Endoscopic Endonasal Approach and Lateral or Posterior Routes[J]. World Neurosurg,2015,83(6):929-936.
[6] Alfieri A, Jho H D, Tschabitscher M. Endoscopic endonasal approach to the ventral cranio-cervical junction: anatomical study[J]. Acta Neurochir (Wien),2002,144(3): 219-225.
[7] El-Banhawy O A, El-Dien A E S, Zolfakar A S,et al. Endoscopic endonasal partial middle turbinectomy approach: adaptability of the procedure in a cadaveric study and in surgery for different sphenoid sinus and skull base lesions[J]. Skull Base, 2006, 16(1): 1-13.
[8] 孙君昭,张剑宁.颅底脊索瘤临床特征及放射外科治疗进展[J].立体定向和功能性神经外科杂志,2012,25(2):123-125.
[9] 孙仕林,夏玉军. 蝶窦的CT与断层解剖比较研究[J].齐鲁医学杂志,2009,24(3):245-247.
[10] 薛 亮,王守森,荆俊杰,等.经鼻入路显露鞍旁结构的三维可视化研究[J].解放军医学杂志, 2012,37(7):725-728.
[11] Jho H D, Ha H G.Endoscopic endonasal skull base surgery; part 3-the clivus and posterior fossa[J]. Minim Invasive Neurosurg,2004,47(1):16-23
[12] 王 鹏,孟春玲,余新光,等.寰椎环形结构完整性和继发性颅底陷入关系的有限元分析[J].军医进修学院学报,2012,33(11):1167-1170.
[13] Justin F. Fraser, M.D.,Gurston G,et al. Endoscopic endonasal transclival resection of chordomas: operative technique, clinical outcome,and review of the literature[J]. J Neurosurg, 2009, 21(8):1-9.
[14] Fischbein N J, Kaplan M J, Holliday R A, et al.Recurrence of clival chordoma along the surgical pathway[J]. ANJR,2000,21(4):578-583.
[15] 王 飞,宗绪毅,张亚卓,等.内镜下经鼻蝶窦入路手术并发颅内感染的诊治[J].中华神经外科杂志,2015,31(1):5-7.
[16] Ishii Y,Tahara S,Teramoto A,et al.Endoscopic endonasal skull base surgery: advantages, limitations, and our techniques to overcome cerebrospinal fluid leakage: technical note[J]. Neurol Med Chir (Tokyo),2014,54(12):983-990.
[17] 桂松柏,宗绪毅,王新生,等. 颅底脊索瘤的内镜经鼻手术治疗分型及入路[J].中华神经外科杂志,2013,29(7):423-425.
[18] Yildirim A E,Divanlioglu D,Cetinalp N E,et al.Endoscopic endonasal treatment of a large clival giant cell tumor invading the cavernous sinus and temporal lobe[J].J Craniofac Surg,2014,5(N2):446-448.
[19] Arbolay O L, González J G, González R H, et al. Extended Endoscopic Endonasal Approach to the Skull Base[J] . Minim Invas Neurosurg,2009,52(1):1-5.
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