本文選題：內(nèi)鏡經(jīng)鼻入路顱底手術(shù) + 內(nèi)鏡顱底解剖��； 參考：《南方醫(yī)科大學(xué)》2015年博士論文

【摘要】：研究背景：顱底中線部位病變位置深,毗鄰腦底重要的神經(jīng)和血管,傳統(tǒng)開顱手術(shù)需要廣泛切開頭皮,鋸下骨瓣、咬開骨窗,牽拉腦組織,甚至破壞正常的顱內(nèi)結(jié)構(gòu)以獲得進(jìn)入病變部位的腦底通道。該過程創(chuàng)傷大,出血多,進(jìn)入顱底后,遇到顱底重要血管、神經(jīng)的阻擋,暴露病變不充分,切除病變需要在血管和神經(jīng)之間的間隙內(nèi)進(jìn)行操作,容易損傷相應(yīng)的血管、神經(jīng),而且難以全切腫瘤,導(dǎo)致腫瘤術(shù)后復(fù)發(fā)機(jī)會(huì)增大,術(shù)后容易出現(xiàn)血管、神經(jīng)損傷的相應(yīng)并發(fā)癥。難以有效解除患者的病痛。內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)是近年來發(fā)展起來的采用硬質(zhì)內(nèi)鏡為光源,經(jīng)鼻腔進(jìn)行顱底中線部位病變切除的一種手術(shù)方式。該手術(shù)方式通過人體自然腔道(鼻腔、蝶竇、篩竇等)到達(dá)顱底中線病變部位,進(jìn)行手術(shù)。手術(shù)入路直接,經(jīng)過鼻腔,通過簡(jiǎn)單的顱底骨質(zhì)磨除,直接到達(dá)相應(yīng)的顱底病灶。避免了傳統(tǒng)開顱手術(shù)時(shí)大范圍頭皮切開、骨瓣骨窗成型、術(shù)中牽拉腦組織等操作過程,不會(huì)遇到顱底重要神經(jīng)、血管阻擋進(jìn)入病灶的通路。從而減少了對(duì)重要神經(jīng)、血管結(jié)構(gòu)造成損傷的可能性,相應(yīng)的減少了手術(shù)的并發(fā)癥。該手術(shù)入路采用4mm的硬質(zhì)內(nèi)鏡經(jīng)鼻腔進(jìn)行手術(shù),內(nèi)鏡可以在鼻腔內(nèi)自由移動(dòng),加上可以采用成角度的內(nèi)鏡觀察病灶,術(shù)中視野開闊,可觀察到手術(shù)部位的全景視野,能夠更準(zhǔn)確、徹底的切除病灶,減少術(shù)后復(fù)發(fā)率。因此內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)受到越來越多的神經(jīng)外科醫(yī)生的青睞。但是,該手術(shù)入路也存在著缺點(diǎn)。首先,內(nèi)鏡下觀察到的解剖結(jié)構(gòu)和顯微鏡以及肉眼觀察到解剖結(jié)構(gòu)存在著差異,由于內(nèi)鏡二維成像的原因,圖像有變形,圖像缺乏立體感,再加上神經(jīng)外科醫(yī)生對(duì)顱底腹側(cè)的解剖結(jié)構(gòu)相對(duì)不熟悉,從而使內(nèi)鏡擴(kuò)大經(jīng)鼻入路在臨床上難以廣泛應(yīng)用；其次,顱底病變往往同時(shí)侵及顱底骨質(zhì)、硬腦膜、甚至顱底腦組織,切除顱底病變后造成顱底骨質(zhì)、硬腦膜缺如,術(shù)后導(dǎo)致無菌的顱腔和有菌的鼻腔相通,造成腦脊液漏、顱內(nèi)感染等并發(fā)癥；第三、內(nèi)鏡擴(kuò)大經(jīng)鼻入路通過雙側(cè)鼻孔進(jìn)行顱底手術(shù),手術(shù)入路外口狹小,手術(shù)操作空間有限,需要術(shù)者具備嫻熟的外科技術(shù)和熟悉內(nèi)鏡下的顱底解剖特點(diǎn)。本研究從內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)的角度,針對(duì)內(nèi)鏡擴(kuò)大經(jīng)鼻入路的缺陷,進(jìn)行解剖學(xué)研究。使廣大臨床醫(yī)師了解該手術(shù)入路下的解剖學(xué)特征,手術(shù)過程中的解剖學(xué)標(biāo)志,術(shù)后骨質(zhì)、硬腦膜缺損可能的重建方式,根據(jù)術(shù)前影像檢查定位顱內(nèi)解剖標(biāo)志。使該手術(shù)入路更容易被廣大醫(yī)師掌握,更好的發(fā)揮該手術(shù)入路的優(yōu)勢(shì)。研究目的：1,研究?jī)?nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)的暴露范圍、解剖標(biāo)志及其與相鄰解剖結(jié)構(gòu)的關(guān)系,為該手術(shù)入路更廣泛的應(yīng)用于臨床提供解剖學(xué)基礎(chǔ)知識(shí)；2,研究鼻腔內(nèi)血管分布情況,探索以鼻后外側(cè)動(dòng)脈為供血?jiǎng)用},以下鼻甲、鼻腔外側(cè)壁、鼻腔底部、鼻中隔粘膜為瓣的后蒂下鼻甲鼻中隔瓣的可行性；3,研究用后蒂下鼻甲鼻中隔瓣重建內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)術(shù)后廣泛顱底骨質(zhì)、硬腦膜缺損的可行性；4,用三維重建CT影像幫助外科醫(yī)生在術(shù)前定位內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)過程中顱內(nèi)的解剖標(biāo)志,減少手術(shù)并發(fā)癥。研究方法：1,模擬內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)解剖5例防腐成人尸頭標(biāo)本。①標(biāo)本準(zhǔn)備：準(zhǔn)備5例經(jīng)頸內(nèi)動(dòng)脈灌注紅色乳膠的防腐尸頭標(biāo)本,用棉簽清洗鼻腔；②模擬手術(shù)：用0度內(nèi)鏡插入右側(cè)鼻孔,辨認(rèn)鼻中隔、下鼻甲、中鼻甲、上鼻甲、鼻后孔、鼻咽、咽鼓管開口、咽鼓管圓枕、蝶篩隱窩、蝶竇開口等鼻腔內(nèi)解剖標(biāo)志；退出內(nèi)鏡后插入左側(cè)鼻孔,觀察以上結(jié)構(gòu),并將左側(cè)中鼻甲向外側(cè)折斷；內(nèi)鏡插入右側(cè)鼻孔,切除右側(cè)中鼻甲和鼻中隔后部約2cm、雙側(cè)蝶竇前壁；模擬內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)依次解剖前顱底、蝶竇、斜坡及顱頸交界區(qū)。2,后蒂下鼻甲鼻中隔瓣的可行性研究。①標(biāo)本制備：8例新鮮冰凍成人尸頭標(biāo)本,常溫下解凍,經(jīng)雙側(cè)頸總動(dòng)脈灌注紅色乳膠,放置于負(fù)20度冰箱內(nèi)冷凍24小時(shí)后取出解凍。②大體解剖：去除下頜骨,在顯微鏡下小心咬出上頜骨水平板、顎骨水平板,同時(shí)保護(hù)好鼻腔底部粘膜。在顯微鏡下小心仔細(xì)分離鼻中隔兩側(cè)粘膜至前顱底,用神經(jīng)剝離子小心剝離粘膜在前顱底的附著處。取出鼻中隔骨質(zhì)和鼻中隔軟骨。沿兩側(cè)鼻腔粘膜之間顱底正中線鋸開標(biāo)本,從而使兩側(cè)鼻中隔、鼻腔底部、鼻腔外側(cè)壁及下鼻甲粘膜保持完好無損。③后蒂下鼻甲鼻中隔瓣的制備：后蒂下鼻甲鼻中隔瓣由9條切線切開鼻腔粘膜而成。首先從蝶竇前壁沿顱底向前剪開鼻中隔粘膜至鼻根部,然后從鼻根部剪開至鼻骨尖端,再?gòu)谋枪羌舛思糸_粘膜至上頜骨鼻棘；第四條切線從蝶竇前壁和前顱底的交點(diǎn)剪開至鼻后孔鼻中隔側(cè)的鼻腔底部；第五條切線從上頜骨鼻棘沿著鼻腔底部向外側(cè),繞過鼻淚管開口的后緣,然后向前到達(dá)下鼻甲頭部的下緣。第六條切線位于冠狀位,從下鼻甲頭的下緣至上緣；第七條切線位于矢狀位,從下鼻甲頭上緣向后,至下鼻甲末端前方約1.5cm；第八條切線位于冠狀位,從上鼻甲末端前方1.5cm至蝶腭孔前緣；第九條切線從鼻后孔鼻中隔側(cè)沿鼻腔底部向外側(cè)到鼻腔外側(cè)壁,然后,在冠狀面,繞過下鼻甲末端,至蝶腭孔后緣。完成這些切線后,把下鼻甲骨向內(nèi)側(cè)折斷,將下鼻甲骨從下鼻甲內(nèi)側(cè)粘膜和下鼻道側(cè)粘膜之間分塊取出,注意保護(hù)好下鼻甲動(dòng)脈。④獲取離體后蒂下鼻甲鼻中隔瓣：在蝶腭孔處橫斷下鼻甲鼻中隔瓣蒂部,獲得離體后蒂下鼻甲鼻中隔瓣,并對(duì)其進(jìn)行解剖學(xué)測(cè)量。⑤顯微解剖：在顯微鏡下解剖后蒂下鼻甲鼻中隔瓣,觀察其血管分布情況,并進(jìn)行解剖學(xué)測(cè)量。3用后蒂下鼻甲鼻中隔瓣重建內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)術(shù)后廣泛顱底骨質(zhì)、硬腦膜缺損的研究。①新鮮冰凍成人尸頭標(biāo)本3例,經(jīng)雙側(cè)頸總動(dòng)脈灌注紅色乳膠,內(nèi)鏡下在右側(cè)鼻腔制作后蒂下鼻甲鼻中隔瓣,藏于右側(cè)上頜竇內(nèi)。②切除右側(cè)中鼻甲、鼻中隔后部2cm、蝶竇前壁,外移對(duì)側(cè)中鼻甲,制造內(nèi)鏡擴(kuò)大經(jīng)鼻入路的手術(shù)通道。然后切除雙側(cè)篩竇、蝶竇下壁、斜坡骨質(zhì),暴露前顱底、中顱底和后顱底腹側(cè)面。③圍繞蝶腭孔將后蒂下鼻甲鼻中隔瓣旋轉(zhuǎn)180度,使后蒂下鼻甲鼻中隔瓣的鼻中隔部分覆蓋于前顱底,鼻腔底部部分覆蓋于鞍底、下鼻甲部分覆蓋于斜坡,觀察其重建廣泛顱底中線骨質(zhì)、硬腦膜缺損的范圍。4,用三維重建薄層CT影像對(duì)內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)顱內(nèi)解剖標(biāo)志進(jìn)行術(shù)前定位研究。①收集111例成人多層重建CT影像,用mimics軟件重建矢狀位和冠狀位CT影像,在三維圖像上定位基點(diǎn)：鼻棘、硬腭后部中點(diǎn),鼻棘和硬腭后部中點(diǎn)之間的連線作為基線；定位觀察點(diǎn)：左/右視神經(jīng)管,左/右破裂孔內(nèi)口,鞍結(jié)節(jié)中點(diǎn),蝶鞍后下壁中點(diǎn)；②測(cè)量各觀察點(diǎn)到基點(diǎn)鼻棘的距離,測(cè)量各觀察點(diǎn)到鼻棘的連線和基線的夾角,測(cè)量左右視神經(jīng)管之間、左右頸內(nèi)動(dòng)脈之間、鞍結(jié)節(jié)中點(diǎn)和蝶鞍后下壁中點(diǎn)之間的距離；③用SPSS20.0對(duì)以上各測(cè)量值進(jìn)行統(tǒng)計(jì)分析。結(jié)果：1,內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)鼻腔內(nèi)的解剖標(biāo)志包括下鼻甲、鼻中隔后部、鼻后孔、蝶篩隱窩、蝶竇開口；前顱底的解剖標(biāo)志包括額隱窩、雞冠、眶內(nèi)側(cè)壁；蝶竇內(nèi)的解剖標(biāo)志包括視神經(jīng)隆起、頸內(nèi)動(dòng)脈隆起、頸內(nèi)動(dòng)脈視神經(jīng)隱窩、鞍底、斜坡隱窩,蝶竇后壁；暴露斜坡的解剖標(biāo)志為蝶竇下壁、破裂孔、翼管；暴露顱頸交界的解剖標(biāo)志為咽鼓管圓枕、枕髁、舌下神經(jīng)管、寰椎前弓、齒突。顱底中線腹側(cè)的暴露范圍,在前顱底,前至額隱窩,兩側(cè)至眶內(nèi)側(cè)壁；蝶骨平臺(tái)處,兩側(cè)可暴露至眶上裂的外側(cè)緣；鞍區(qū)可暴露的側(cè)界為圓孔；斜坡區(qū)側(cè)界為頸動(dòng)脈管內(nèi)口；枕髁處可暴露的最外側(cè)為舌下神經(jīng)管前緣；向下可暴露至樞椎上緣。顱底腹側(cè)中線可暴露的神經(jīng)、血管結(jié)構(gòu)包括：直回、大腦縱裂、大腦前動(dòng)脈、前交通動(dòng)脈、嗅球、嗅束、視神經(jīng)、視交叉、眼動(dòng)脈、頸內(nèi)動(dòng)脈、垂體、垂體柄、乳突體、第三腦室底、大腦后動(dòng)脈、后交通動(dòng)脈、基底動(dòng)脈、動(dòng)眼神經(jīng)、小腦上動(dòng)脈、滑車神經(jīng)、眼神經(jīng)、上頜神經(jīng)、展神經(jīng)、腦橋動(dòng)脈、椎動(dòng)脈、小腦后下動(dòng)脈、脊髓前動(dòng)脈、面神經(jīng)、前庭蝸神經(jīng)、舌咽神經(jīng)、迷走神經(jīng)、副神經(jīng)、舌下神經(jīng)、第一、二頸神經(jīng)、腦橋、延髓和上頸髓腹側(cè)。2,下鼻甲動(dòng)脈平均2.50±0.52支,鼻中隔動(dòng)脈平均2.50±0.52支,這些動(dòng)脈發(fā)出吻合支形成下鼻甲動(dòng)脈網(wǎng)和鼻中隔動(dòng)脈網(wǎng),在下鼻甲動(dòng)脈網(wǎng)和鼻中隔動(dòng)脈網(wǎng)之間存在恒定的吻合動(dòng)脈,吻合動(dòng)脈的數(shù)量為3.19±1.47支,其中最大吻合動(dòng)脈的平均直徑0.40mm±1.10mm(范圍0.24-0.60mm)。后蒂下鼻甲鼻中隔瓣的面積為3090.69±288.08mm2(范圍2612.97mm2-3880.09mm2)；其蒂的長(zhǎng)度為11.21±2.40mm(范圍5.00mm-14.74mm)；瓣的最窄寬度為25.21±2.29mm(范圍22.36-30.23mm)；最寬寬度為44.53±5.02mm(范圍36.45mm-54.10mm)；長(zhǎng)度為100.65±5.61mm(范圍91.43-109.44mm)。3,后蒂下鼻甲鼻中隔瓣覆蓋顱底范圍前端至額隱窩,下端至枕骨大孔,側(cè)方在前顱底至雙側(cè)眶內(nèi)側(cè)壁,中顱底覆蓋雙側(cè)的海綿竇,后顱底覆蓋雙側(cè)頸內(nèi)動(dòng)脈之間的斜坡。由于后蒂下鼻甲鼻中隔瓣的蒂部長(zhǎng)度有限,在上斜坡部分,對(duì)側(cè)部分上斜坡不能完全覆蓋。對(duì)于左側(cè)鼻腔的后蒂下鼻甲鼻中隔瓣,重建顱底硬腦膜缺損時(shí)旋轉(zhuǎn)方向?yàn)轫槙r(shí)針；右側(cè)鼻腔的后蒂下鼻甲鼻中隔瓣則剛好相反,旋轉(zhuǎn)方向?yàn)槟鏁r(shí)針。4,從鼻棘到視神經(jīng)管的平均距離為73.12±4.10 mm,從視神經(jīng)管到鼻棘的連線和基線的夾角的平均角度39.79±3.13度；從破裂孔內(nèi)側(cè)緣到鼻棘的平均距離是79.91±4.01mm,從破裂孔內(nèi)側(cè)緣到鼻棘的連線和基線的夾角的平均角度是23.27±2.89度。從鞍結(jié)節(jié)中點(diǎn)和鞍底后緣中點(diǎn)到鼻棘的平均距離分別是76.16±4.56mm和82.05-4.81mm,相應(yīng)連線和基線的夾角分別是34.97±3.24度和26.39±3.51度。雙側(cè)破裂孔之間、雙側(cè)視神經(jīng)管之間的平均距離分別是22.54±3.25mm和23.44±3.49mm。從鞍結(jié)節(jié)中點(diǎn)到鞍底后緣中點(diǎn)的平均距離是13.33±1.87mm。結(jié)論：1,內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)可暴露廣泛顱底腹側(cè)中線部位,路徑直接、視野廣泛,避免了牽拉腦組織,避開了腦底重要血管神經(jīng)的阻擋,可作為顱底中線部位：包括前顱底、中顱底、斜坡和顱頸交界區(qū)硬膜外或者硬膜下病變的有效手術(shù)治療方法,對(duì)于某些其他手術(shù)入路無法切除的病變,可作為首選治療方式。該入路最常見的手術(shù)問題是防止術(shù)后腦脊液漏和控制出血。內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)需要研發(fā)精細(xì)的手術(shù)器械、更有效的止血材料和重建顱底缺損的方法。只有在內(nèi)鏡應(yīng)用方面進(jìn)行過內(nèi)鏡尸體解剖研究或者經(jīng)過內(nèi)鏡經(jīng)鼻入路顱底手術(shù)培訓(xùn)的有經(jīng)驗(yàn)的神經(jīng)外科醫(yī)師可以開展內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)。2,以鼻后外側(cè)動(dòng)脈為供血?jiǎng)用}的后蒂下鼻甲鼻中隔瓣的血供基礎(chǔ)從解剖學(xué)的角度是可行的,結(jié)合既往的研究結(jié)果,鼻后外側(cè)動(dòng)脈可向整個(gè)粘膜瓣供血,而不會(huì)出現(xiàn)缺血壞死的情況；該瓣是目前報(bào)道的鼻內(nèi)最大的帶蒂粘膜瓣。3,后蒂下鼻甲鼻中隔瓣位于鼻內(nèi),其用于重建內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)后顱底骨質(zhì)、硬腦膜缺損的范圍廣泛,避免了應(yīng)用鼻外帶蒂筋膜瓣重建內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底廣泛骨質(zhì)硬腦膜缺損時(shí)瓣的轉(zhuǎn)移過程,從而減少了相應(yīng)的并發(fā)癥,可作為一種潛在的重建廣泛顱底骨質(zhì)、硬腦膜缺損的鼻內(nèi)帶蒂粘膜瓣。4,視神經(jīng)管、破裂孔、鞍結(jié)節(jié)、鞍底后緣中點(diǎn)是內(nèi)鏡擴(kuò)大經(jīng)鼻入路顱底手術(shù)的解剖標(biāo)志,薄層三維重建CT影像可對(duì)這些解剖標(biāo)志在術(shù)前進(jìn)行立體定位評(píng)估,從而有助于術(shù)者在術(shù)中確認(rèn)這些手術(shù)標(biāo)志,避免損傷重要的血管神經(jīng)結(jié)構(gòu),減少手術(shù)并發(fā)癥,對(duì)于鞍前型、甲介型蝶鞍來說,術(shù)前評(píng)估尤其重要。對(duì)每位病人進(jìn)行個(gè)體化的評(píng)估,更有利于術(shù)中對(duì)這些解剖標(biāo)志的辨認(rèn)。
[Abstract]:Background: the location of the lesion in the midline of the skull is deep, adjacent to the important nerve and blood vessels of the brain. Traditional craniotomy requires extensive incision of the scalp, sawing the bone flap, biting the bone window, pulling the brain tissue, and even destroying the normal intracranial structure to obtain the brain bottom passage into the lesion. The process is traumatic, bleeding, and encounters after the skull base. The important blood vessels of the skull base, the nerve block, the exposure of the disease is not sufficient, the removal of the lesion needs to operate within the space between the blood vessels and nerves. It is easy to damage the corresponding blood vessels and nerves, and it is difficult to cut the tumor completely, which causes the recurrence of the tumor after operation and the postoperative complications of vascular and nerve injury. The endoscopic enlargement of the transnasal approach to the skull base is a new method of resection of the middle line of the skull through the nasal cavity, which has been developed in recent years by using the hard endoscopy as the light source. The operation is performed through the natural cavity of the human body (nasal cavity, sphenoid sinus, ethmoid sinus and so on) to the middle line of the skull base, and the operation is performed directly. Through the nasal cavity, the skull base is directly reached through the simple skull base bone grinding. It avoids the large scalp incision in the traditional craniotomy, the bone flap bone window molding, and the operation process of pulling the brain tissue during the operation. It will not meet the important nerve of the skull base and the blood vessels obstruct the access to the lesion. Thus, the important nerve and the vascular structure are reduced. The possibility of injury, which reduces the complication of the operation, is operated through the nasal cavity of the 4mm's hard endoscope, the endoscopy can move freely within the nasal cavity, and the endoscopy can be used to observe the focus, and the visual field is broadened to observe the panoramic view of the hand. It can be more accurately and thoroughly excised. The endoscopic enlargement of the transnasal approach to the skull base is therefore favored by more and more neurosurgeons. However, there are also shortcomings in the surgical approach. First, the anatomical structure observed under the endoscope and the anatomical structure observed by the naked eye are different, and the reasons for the two-dimensional imaging of the endoscope are shown. Such as distortion, lack of stereoscopic images, and the relative unfamiliarity of the neurosurgeon with the anatomical structure of the ventral base of the skull, the endoscopic enlargement of the transnasal approach is difficult to be widely used clinically. Secondly, the skull base lesions often involve the skull base, the dura, and even the cranial tissue, and the skull base is excised and the skull base is hard to be caused by the removal of the skull base. The absence of meninges, which causes the aseptic cranial cavity and the bacterial nasal cavity, causes cerebrospinal fluid leakage, intracranial infection and other complications; third, endoscopic enlargement of the transnasal approach through bilateral nostrils for skull base surgery, the surgical approach is narrow, and the operation space is limited. The surgeons need skilled surgical techniques and know the skull base under endoscopy. An anatomical study of endoscopic enlargement of the nasal approach to the endoscopic enlargement of the transnasal approach. The anatomical features of the surgical approach, the anatomical marks of the operation, the possible reconstruction of the postoperatively bone and the defect of the dura meninges, according to the preoperative imaging examination, were made in this study. The surgical approach is easier to be mastered by the general physician and better to give full play to the advantages of the surgical approach. Objective: 1. To study the scope of endoscopic enlargement of the transnasal approach to the skull base surgery, the anatomical signs and their relationship with adjacent anatomical structures, and to provide a more extensive application of the surgical approach to clinical anatomy. 2, study the distribution of the blood vessels in the nasal cavity, explore the feasibility of the posterior pedicle of the inferior turbinate with the posterior lateral nasal artery as the supply artery, the inferior turbinate, the lateral wall of the nasal cavity, the bottom of the nasal cavity, the nasal septum mucosa as the flap, and 3. The feasibility of cranial base bone and dura defect; 4, using three-dimensional reconstruction of CT images to help the surgeon to expand the intracranial anatomic markers in the process of endoscopic sinus surgery to reduce the surgical complications. Study methods: 1, 5 cases of adult cadaver head specimens were dissected by endoscopic enlargement of nasal approach cranial hand surgery. (1) specimen preparation 5 specimens of the anticorrosive cadaver head with red latex perfusion through the internal carotid artery were prepared with a cotton swab to clean the nasal cavity; (2) a simulated operation: a 0 degree endoscope was inserted into the right nostril to identify the nasal septum, inferior turbinate, nasal turbinate, upper turbinate, posterior nasopharynx, nasopharynx, Eustachian tube opening, Eustachian tube round pillow, sphenoid fossa, sphenoid sinus opening and other anatomic markers. The left nostril was inserted into the left nostril to observe the above structure, and the left middle turbinate was broken to the lateral. The right nostril was inserted into the right nostril to remove the right middle turbinate and the posterior septum of the nasal septum about 2cm and the anterior wall of the sphenoid sinus. The anterior skull base, the sphenoid sinus, the ramp and the craniofacial junction area of the anterior skull base, the sphenoid sinus, the ramp and the craniofacial junction area were.2, and the inferior turbinate nasal septum was followed by the endoscopy. Feasibility study of valve. (1) specimen preparation: 8 cases of fresh frozen adult cadaver head specimens, frozen at normal temperature, red latex perfusion through bilateral common carotid artery, and frozen for 24 hours in negative 20 degrees fridge. Gross anatomy: remove the mandible, carefully bite the horizontal plate of the maxilla, the horizontal plate of the jaw, and protect the horizontal plate at the same time. The mucosa at the bottom of the nasal cavity. Carefully separate the mucous membranes on both sides of the nasal septum to the anterior skull base carefully and carefully peel off the mucous membrane at the anterior skull base with nerve ion. Remove the nasal septum and nasal septum cartilage. The nasal septum, the bottom of the nasal cavity, the lateral wall of the nasal cavity, and the lateral wall of the nasal cavity and the lateral wall of the nasal cavity are removed. The mucous membrane of the inferior turbinate remains intact. (3) the preparation of the inferior turbinate septum flap in the posterior pedicle: the posterior inferior turbinate nasal septum is cut through the nasal mucosa by 9 tangents. First, cut the nasal septum from the anterior wall of the sphenoidal sinus to the nasal root, then cut from the nasal root to the tip of the nasal bone, and then cut the mucous membrane from the tip of the nasal bone to the maxilla nose spines. The fourth cut lines cut from the anterior wall of the sphenoidal sinus and the anterior skull base to the bottom of the nasal septum on the nasal septum, and the fifth cut lines from the maxillary nasal spines along the bottom of the nasal cavity, around the posterior edge of the nasolacrimal duct opening, and then forward to the lower edge of the head of the inferior turbinate. The sixth lines were located at the coronal, from the lower edge of the inferior turbinate to the lower edge of the nose. Margin; seventh tangents are located in the sagittal position, from the upper upper edge of the inferior turbinate to about 1.5cm at the end of the inferior turbinate; the eighth tangent line is located in the coronal position, from the end of the upper turbinate to the anterior edge of the sphenopalatine hole, and the ninth cut lines from the posterior nasal septum to the lateral of the nasal cavity to the lateral wall of the nasal cavity, then, at the coronal, around the inferior turbinate at the coronal surface. End, to the posterior margin of the sphenopalatine hole. After the completion of these lines, the inferior turbinate was broken to the medial side, the inferior turbinate was removed from the medial mucous membrane of the inferior turbinate and the inferior nasal mucosa, and the inferior turbinate artery was protected. (4) to obtain the inferior turbinate septum flap in the posterior pedicle: the pedicle of the inferior turbinate and nasal septum at the sphenopalatine hole was obtained. After the isolation, the isolated nasal septum was obtained. Pedicle inferior turbinate nasal septum and anatomical measurement. 5. Microanatomy: dissection of the inferior turbinate nasal septum under microscope and observe the distribution of the vessels. The anatomical measurement of the.3 with the posterior pedicle inferior turbinate nasal septum reconstruction endoscope enlarges the extensive skull base bone and the dura mater defect after the cranial surgery. (1) 3 cadaver specimens of fresh frozen adult cadavers were perfused with red latex through bilateral common carotid artery and the inferior turbinate nasal septum after making the right nasal cavity and hidden in the right maxillary sinus after making the right nasal cavity. Second, the right middle turbinate, the posterior septum of the nasal septum 2cm, the anterior wall of the sphenoid sinus, the lateral middle turbinate, and the endoscopic enlargement of the nasal passage were made. And then excised. Bilateral ethmoid sinus, inferior wall of sphenoid sinus, slope bone, anterior skull base, middle skull base and posterior skull base ventral side. 3. Revolve 180 degrees around the inferior turbinate nasal septum around the sphenopalatine hole. The nasal septum part of the inferior turbinate nasal septum covers the anterior skull base, the bottom part of the nasal cavity covers the saddle bottom, the inferior turbinate part covers the slope and the reconstruction is widely rebuilt. The range of median skull base line bone and dura mater defect.4. A three-dimensional reconstruction thin layer CT image was used to study the preoperative localization of the intracranial anatomic markers by endoscopic sinus surgery. (1) 111 cases of adult multilevel reconstruction of CT images were collected and mimics software was used to reconstruct the sagittal and coronal CT images, and the base points of the nasal spine and the hard palate were located on the three-dimensional images. The line between the middle point of the posterior part of the posterior part and the middle point of the posterior part of the hard palate was taken as the baseline; the location of the observation point: the left / right optic canal, the left / right ruptured orifice, the middle point of the sellar tubercle, the middle point of the posterior inferior wall of the saddle; and the measurement of the distance between the observation points to the base point of the nasal Spina, the angle of the connection lines and the baseline of the nasal spines at each observation point, and the measurement of the left and right optic canal The distance between the left and right internal carotid arteries, the middle point of the saddle tubercle and the middle of the inferior wall of the saddle after the sellar; (3) the results were statistically analyzed with SPSS20.0. Results: 1, the endoscopic enlargement of the nasal cavity of the nasal cavity through the nasal approach included the inferior turbinate, the posterior nasal septum, the posterior nasal cavity, the sphenoid fossa, the sphenoid sinus, and the anatomy of the anterior skull base. The signs include the frontal recess, the cockscomb, and the medial orbital wall; the anatomic markers in the sphenoidal sinus include the optic nerve protuberance, the internal carotid artery protuberance, the internal carotid artery optic recess, the saddle floor, the ramp recess, the posterior wall of the sphenoid sinus, and the anatomical marks of the exposed ramp for the inferior wall of the sphenoid sinus, the ruptured hole, and the wing tube; the anatomical signs of the craniocervial junction are the eustachian tube, the occipital condyle, and the sublingual gland. Nerve canal, anterior arch of atlas, odontoid process. The exposure of the ventral side of the middle line of the skull at the anterior skull base, the anterior to the frontal recess, both sides to the medial orbital wall; the lateral border of the orbital fissure at the sphenoid platform; the exposed lateral boundary of the saddle area is a circular hole; the lateral boundary of the slope is the internal canal of the carotid canal; the most lateral of the occipital condyle is the lateral sublingual canal. Anterior margin; exposing to the upper edge of the axis. The nerves that can be exposed in the middle of the ventral side of the skull include: straight gyrus, longitudinal brain fissure, anterior cerebral artery, anterior communicating artery, olfactory bulb, olfactory bundle, optic nerve, optic chiasma, ophthalmic artery, internal carotid artery, pituitary, pituitary stalk, lactoad, third ventricle base, posterior cerebral artery, posterior communicating artery, basilar artery, and movement The eyes, superior cerebellar artery, trochlear nerve, eye meridian, maxillary nerve, abduction nerve, pontine artery, vertebral artery, posterior inferior cerebellar artery, anterior spinal artery, facial nerve, vestibule nerve, glossopharyngeal nerve, vagus nerve, accessory nerve, hypoglossal nerve, first, second cervical nerves, pontine, medulla and upper cervical ventral.2, and inferior turbinate artery averages 2.50 + 0.52 branches, nose The median of the septum artery was 2.50 + 0.52 branches. These arteries emit the anastomosis branch to form the inferior turbinate artery network and the nasal septum artery network. There is a constant anastomosis artery between the inferior turbinate artery network and the nasal septum artery network. The number of the anastomotic arteries is 3.19 + 1.47 branches, the average diameter of the maximum anastomosis artery is 0.40mm + 1.10mm (range 0.24-0.60mm). The area of inferior turbinate nasal septum was 3090.69 + 288.08mm2 (range 2612.97mm2-3880.09mm2), the length of the pedicle was 11.21 + 2.40mm (range 5.00mm-14.74mm), the narrowest width of the flap was 25.21 + 2.29mm (range 22.36-30.23mm), the width of the flap was 44.53 + 5.02mm (range 36.45mm-54.10mm), and the length was 100.65 + 5.61mm (91.43-109.44mm).3. The posterior inferior turbinate nasal septum covers the front-end of the skull base to the frontal recess, the lower end to the occipital foramen, the side of the anterior skull base to the medial orbital medial wall, the middle skull base covered with bilateral cavernous sinus, the posterior skull base covered with the bilateral internal carotid artery, and the pedicle of the inferior turbinate nasal septum is limited in the upper slope part and the opposite part. The clivus can not be completely covered. For the inferior turbinate inferior turbinate septum flap of the left nasal cavity, the rotation direction of the skull base dural defect is clockwise; the inferior turbinate septum flap in the right nasal posterior pedicle is just the opposite, the rotation direction is reverse clockwise.4, the average distance from the nasal spines to the optic canal is 73.12 + 4.10 mm, from the optic canal to the nasal spines. The average angle of the angle between the line and the baseline is 39.79 + 3.13 degrees; the average distance from the medial edge of the rupture hole to the nasal spine is 79.91 + 4.01mm.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R322.31;R765.9
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本文編號(hào)：1991847