神經(jīng)內(nèi)鏡輔助下經(jīng)鎖孔入路到達(dá)鞍區(qū)的解剖學(xué)比較研究
發(fā)布時間：2018-08-22 11:41
【摘要】：目的:比較研究神經(jīng)內(nèi)鏡輔助顯微鏡下經(jīng)眶上鎖孔入路、翼點(diǎn)鎖孔入路、胼胝體-穹窿間鎖孔入路中鞍區(qū)重要結(jié)構(gòu)的解剖學(xué)特點(diǎn),并對三種手術(shù)入路的顯露范圍進(jìn)行定量比較研究。為神經(jīng)內(nèi)鏡輔助顯微鏡下經(jīng)鎖孔入路治療鞍區(qū)病變提供局部應(yīng)用解剖學(xué)資料,為臨床中治療鞍區(qū)病變選擇適當(dāng)?shù)氖中g(shù)入路提供理論指導(dǎo)。 方法:將福爾馬林溶液固定的5具帶頸成人尸頭標(biāo)本以酒精浸泡,解剖頸部血管,插管沖洗,灌注乳膠。然后分別采用經(jīng)眶上鎖孔、翼點(diǎn)鎖孔和胼胝體-穹窿間鎖孔三種手術(shù)入路開顱,模擬手術(shù)過程,通過手術(shù)顯微鏡及神經(jīng)內(nèi)鏡對鞍區(qū)結(jié)構(gòu)進(jìn)行解剖觀察,比較不同鎖孔入路的切口及骨窗、鞍區(qū)各手術(shù)間隙在模擬手術(shù)過程中的應(yīng)用價值。去除部分顱骨及腦組織后測量相關(guān)數(shù)據(jù),應(yīng)用Heron’s公式計(jì)算出各手術(shù)入路下鞍區(qū)的暴露范圍,采用SPSS14.0軟件進(jìn)行統(tǒng)計(jì)分析后,比較各手術(shù)入路的顯露范圍。 結(jié)果:(1)數(shù)據(jù)結(jié)果:經(jīng)眶上鎖孔入路、翼點(diǎn)鎖孔入路、胼胝體-穹窿間鎖孔入路對鞍區(qū)的顯露面積分別為:279.33±13.633渵2、290.55±14.553渵2、86.47±5.333渵2。翼點(diǎn)鎖孔入路比眶上鎖孔入路顯露范圍大,差異有統(tǒng)計(jì)學(xué)意義(P0.05);眶上鎖孔入路比胼胝體-穹窿間入路顯露范圍大,差異有統(tǒng)計(jì)學(xué)意義(P0.05);翼點(diǎn)鎖孔入路比胼胝體-穹窿間入路顯露范圍大,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。(2)應(yīng)用神經(jīng)內(nèi)鏡可以不牽拉重要神經(jīng)、血管等結(jié)構(gòu)而經(jīng)其間狹小的間隙達(dá)到對深部視野全景化的觀察,可以消除顯微鏡下的視野盲區(qū),而且對細(xì)微結(jié)構(gòu)特別是穿支小血管的顯示較清晰。(3)經(jīng)眶上和翼點(diǎn)鎖孔入路在顯微鏡下和用不同角度的神經(jīng)內(nèi)鏡在不同解剖間隙內(nèi)操作都能較好的顯露和觀察鞍區(qū)的重要結(jié)構(gòu),包括前床突、視神經(jīng)、視交叉、鞍膈、垂體柄、Willis環(huán)及細(xì)小的穿支動脈、鞍背、后床突、動眼神經(jīng)等,并可看到基底動脈頂部和腦干腹側(cè)結(jié)構(gòu)。經(jīng)胼胝體-透明隔-穹窿間鎖孔入路對大腦前動脈A1段、前交通動脈,視交叉和視束的暴露和觀察較好。(4)經(jīng)眶上鎖孔入路對第Ⅰ、Ⅱ、Ⅳ間隙暴露較好,第Ⅲ間隙只能部分暴露。在第I間隙可清楚地觀察視交叉,視神經(jīng)、垂體柄、鞍膈、雙側(cè)頸內(nèi)動脈和后交通動脈、垂體前葉。進(jìn)入第Ⅱ間隙可見頸內(nèi)動脈和后交通動脈及其穿支動脈。經(jīng)第Ⅲ間隙向后打開Liliequist膜進(jìn)入腳間池,可見基底動脈分叉部、雙側(cè)大腦后動脈、小腦上動脈、動眼神經(jīng)。牽開額葉直回,經(jīng)第Ⅳ間隙可觀察大腦前動脈、前交通動脈和Heubner返動脈。(5)經(jīng)翼點(diǎn)入路對鞍區(qū)各間隙均可顯露,對第Ⅱ、Ⅲ間隙的顯露最佳,進(jìn)入第1、Ⅳ間隙需斜行。該入路能從側(cè)方更清楚地觀察頸內(nèi)動脈、后交通動脈和脈絡(luò)膜前動脈及其穿支動脈。后交通動脈和動眼神經(jīng)與小腦幕游離緣之間無穿支動脈,經(jīng)該間隙向后打開Liliequist膜后,越過后床突進(jìn)入腳間池,可見基底動脈分叉部、雙側(cè)大腦后動脈、小腦上動脈及動眼神經(jīng),并可觀察腦干腹外側(cè)面。切除額葉直回后可斜行進(jìn)入第Ⅳ間隙。(6)經(jīng)胼胝體-透明隔-穹窿間鎖孔入路對第Ⅳ間隙顯露最佳,但無法顯露其它間隙。 結(jié)論:(1)三種入路對鞍區(qū)的顯露范圍不同,翼點(diǎn)鎖孔入路顯露的面積最大,眶上鎖孔入路次之,經(jīng)胼胝體-穹窿間鎖孔入路最小。(2)在神經(jīng)內(nèi)鏡輔助顯微鏡下經(jīng)眶上、翼點(diǎn)鎖孔入路都能觀察到鞍區(qū)及其周圍的重要神經(jīng)、血管等結(jié)構(gòu),包括基底動脈及其分支和腦干腹側(cè)面結(jié)構(gòu),經(jīng)胼胝體-透明隔-穹窿間鎖孔入路顯露鞍上和三腦室前部結(jié)構(gòu)較清晰。(3)神經(jīng)內(nèi)鏡具有多角度視野、巨大的景深、可以隨鏡體深入延伸視野等優(yōu)點(diǎn),可以消除手術(shù)操作中顯微鏡下的視野盲區(qū)。在模擬手術(shù)入路過程中,應(yīng)用神經(jīng)內(nèi)鏡可以不牽拉重要神經(jīng)、血管等結(jié)構(gòu)而經(jīng)其間狹小的間隙達(dá)到對深部視野全景化的觀察,而且對細(xì)微結(jié)構(gòu)特別是穿支小血管的顯示較清晰,優(yōu)于顯微鏡。(4)不同手術(shù)入路具有不同優(yōu)勢。經(jīng)眶上鎖孔入路對于鞍區(qū)第I、Ⅱ間隙顯露較好,能充分顯露Willis環(huán)前部,視野較為直接,對中線部位、同側(cè)鞍旁及部分對側(cè)結(jié)構(gòu)的顯露較充分。經(jīng)翼點(diǎn)鎖孔入路對鞍區(qū)四個手術(shù)間隙及全部Willis環(huán)均可顯露,對鞍上、同側(cè)鞍旁和鞍后均可顯露,尤其對第Ⅱ、Ⅲ間隙的顯露最具優(yōu)勢,而且經(jīng)第Ⅲ間隙能清楚地觀察到后交通動脈的全長和穿支動脈。經(jīng)胼胝體-透明隔-穹窿間鎖孔入路對第Ⅳ間隙的顯露最直接,對鞍上后部和第三腦室前部顯露較好。
[Abstract]:Objective:To compare the anatomical characteristics of the important structures in the sellar region through supraorbital keyhole approach,pterional keyhole approach and callosal-fornix keyhole approach under neuroendoscope-assisted microscope,and to quantitatively compare the exposure ranges of the three surgical approaches. Local applied anatomical data can provide theoretical guidance for the selection of appropriate surgical approaches for the treatment of sellar lesions.
Methods: Five adult cadaveric heads with cervix fixed by formalin solution were immersed in alcohol, dissected the cervical vessels, washed with intubation and perfused with latex. Anatomical observation was carried out to compare the application value of incision and bone window of different keyhole approaches and surgical space in the sellar region in the simulated operation process. The extent of exposure.
Results: (1) Data Resul: (1) The exposed area of suporbitakeyhole approach, pterkeyhole approach, corpus callosum-forniculinterkeyhole approach to the sellar region was 279.33 (+ 13.63) 2, 290.55 (+ 14.55) 2, 86.47 (+ 5.33 (+ 5.33) 2) 2, 86.47 (+ 5.33) 2. The exposearea of pterkeyhole approach was significantly larger than supororbitakeyhole approach (P 0.05); the exposearea of supsupsupsuporororbitakeyhole approach was 279.33 (+ 13.63) 2, 2, 2, 20.55 (+ 14.33 (+ 14.63) 2, 86.47 (+14.55 (+ 14.55 (+2), In the meantime, it is necessary to study the relationship between the two. Body-fornix approach showed a wide range of exposure, the difference was statistically significant (P 0.05); pterional keyhole approach than the callosal-fornix approach revealed a larger range, the difference was statistically significant (P 0.05). (2) The application of neuroendoscopy can not pull important nerves, blood vessels and other structures through the narrow gap between the deep visual field panoramic observation, can be. (3) The important structures of the sellar region, including the anterior clinoid process, optic nerve and optic chiasma, can be well exposed and observed through the supraorbital and pterional keyhole approach under microscope and by neuroendoscopy with different angles in different anatomical spaces. Sellar diaphragm, pituitary stalk, Willis ring and fine perforator artery, dorsal sellar, posterior clinoid process, oculomotor nerve, and the top of basilar artery and ventral structure of brainstem can be seen. The exposure and observation of A1 segment of anterior cerebral artery, anterior communicating artery, optic chiasma and optic tract by transcorbital keyhole approach are better. The interval I I, IV was well exposed and the interval I I I was only partially exposed. The optic chiasma, optic nerve, pituitary stalk, sellar diaphragm, bilateral internal carotid artery and posterior communicating artery, anterior pituitary lobe were clearly observed in the interval I. The internal carotid artery, posterior communicating artery and its perforating artery were visible in the interval I I. The Liquist membrane was opened backwards into the foot through the interval I I I. The bifurcation of basilar artery, bilateral posterior cerebral artery, superior cerebellar artery and oculomotor nerve can be seen in the cistern. The anterior cerebral artery, anterior communicating artery and Heubner's recurrent artery can be observed through the fourth space after the frontal lobe is pulled apart. The internal carotid artery, the posterior communicating artery, the anterior choroidal artery and their perforating arteries can be observed more clearly through the lateral approach. The superior cerebellar artery and the oculomotor nerve can be observed on the ventrolateral side of the brainstem. After the frontal lobe is resected, it can obliquely enter the space IV. (6) The keyhole approach through the corpus callosum-septum pellucidum-fornix is the best way to expose the space IV, but other spaces can not be exposed.
CONCLUSIONS: (1) Three approaches have different exposure ranges to the sellar region, the pterional keyhole approach has the largest exposure area, the supraorbital keyhole approach is the second, and the transcorpus-fornix keyhole approach is the smallest. (2) Under the neuroendoscope-assisted microscope, the pterional keyhole approach can observe the important nerves and blood vessels around the sellar region, including the base. The basilar artery and its branches and ventral brainstem structures were clearly revealed through the corpus callosum-septum pellucidum-fornix keyhole approach. (3) Neuroendoscopy has many advantages, such as multi-angle vision, huge depth of field, and can extend the field of vision with the lenses deeply. It can eliminate the blind area under the microscope in the operation. During the operation, endoscopic neuroendoscopy can achieve panoramic observation of deep visual field without pulling important nerves and blood vessels through the narrow space between them, and it is better than microscopy in displaying fine structures, especially perforating vessels. (4) Different surgical approaches have different advantages. The anterior part of the Willis ring can be fully exposed, and the visual field is direct. The median part, the ipsilateral parasellar and some contralateral structures are fully exposed. The length of the posterior communicating artery and the perforating artery could be clearly observed through the third space.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2011
【分類號】：R322
本文編號：2196992
[Abstract]:Objective:To compare the anatomical characteristics of the important structures in the sellar region through supraorbital keyhole approach,pterional keyhole approach and callosal-fornix keyhole approach under neuroendoscope-assisted microscope,and to quantitatively compare the exposure ranges of the three surgical approaches. Local applied anatomical data can provide theoretical guidance for the selection of appropriate surgical approaches for the treatment of sellar lesions.
Methods: Five adult cadaveric heads with cervix fixed by formalin solution were immersed in alcohol, dissected the cervical vessels, washed with intubation and perfused with latex. Anatomical observation was carried out to compare the application value of incision and bone window of different keyhole approaches and surgical space in the sellar region in the simulated operation process. The extent of exposure.
Results: (1) Data Resul: (1) The exposed area of suporbitakeyhole approach, pterkeyhole approach, corpus callosum-forniculinterkeyhole approach to the sellar region was 279.33 (+ 13.63) 2, 290.55 (+ 14.55) 2, 86.47 (+ 5.33 (+ 5.33) 2) 2, 86.47 (+ 5.33) 2. The exposearea of pterkeyhole approach was significantly larger than supororbitakeyhole approach (P 0.05); the exposearea of supsupsupsuporororbitakeyhole approach was 279.33 (+ 13.63) 2, 2, 2, 20.55 (+ 14.33 (+ 14.63) 2, 86.47 (+14.55 (+ 14.55 (+2), In the meantime, it is necessary to study the relationship between the two. Body-fornix approach showed a wide range of exposure, the difference was statistically significant (P 0.05); pterional keyhole approach than the callosal-fornix approach revealed a larger range, the difference was statistically significant (P 0.05). (2) The application of neuroendoscopy can not pull important nerves, blood vessels and other structures through the narrow gap between the deep visual field panoramic observation, can be. (3) The important structures of the sellar region, including the anterior clinoid process, optic nerve and optic chiasma, can be well exposed and observed through the supraorbital and pterional keyhole approach under microscope and by neuroendoscopy with different angles in different anatomical spaces. Sellar diaphragm, pituitary stalk, Willis ring and fine perforator artery, dorsal sellar, posterior clinoid process, oculomotor nerve, and the top of basilar artery and ventral structure of brainstem can be seen. The exposure and observation of A1 segment of anterior cerebral artery, anterior communicating artery, optic chiasma and optic tract by transcorbital keyhole approach are better. The interval I I, IV was well exposed and the interval I I I was only partially exposed. The optic chiasma, optic nerve, pituitary stalk, sellar diaphragm, bilateral internal carotid artery and posterior communicating artery, anterior pituitary lobe were clearly observed in the interval I. The internal carotid artery, posterior communicating artery and its perforating artery were visible in the interval I I. The Liquist membrane was opened backwards into the foot through the interval I I I. The bifurcation of basilar artery, bilateral posterior cerebral artery, superior cerebellar artery and oculomotor nerve can be seen in the cistern. The anterior cerebral artery, anterior communicating artery and Heubner's recurrent artery can be observed through the fourth space after the frontal lobe is pulled apart. The internal carotid artery, the posterior communicating artery, the anterior choroidal artery and their perforating arteries can be observed more clearly through the lateral approach. The superior cerebellar artery and the oculomotor nerve can be observed on the ventrolateral side of the brainstem. After the frontal lobe is resected, it can obliquely enter the space IV. (6) The keyhole approach through the corpus callosum-septum pellucidum-fornix is the best way to expose the space IV, but other spaces can not be exposed.
CONCLUSIONS: (1) Three approaches have different exposure ranges to the sellar region, the pterional keyhole approach has the largest exposure area, the supraorbital keyhole approach is the second, and the transcorpus-fornix keyhole approach is the smallest. (2) Under the neuroendoscope-assisted microscope, the pterional keyhole approach can observe the important nerves and blood vessels around the sellar region, including the base. The basilar artery and its branches and ventral brainstem structures were clearly revealed through the corpus callosum-septum pellucidum-fornix keyhole approach. (3) Neuroendoscopy has many advantages, such as multi-angle vision, huge depth of field, and can extend the field of vision with the lenses deeply. It can eliminate the blind area under the microscope in the operation. During the operation, endoscopic neuroendoscopy can achieve panoramic observation of deep visual field without pulling important nerves and blood vessels through the narrow space between them, and it is better than microscopy in displaying fine structures, especially perforating vessels. (4) Different surgical approaches have different advantages. The anterior part of the Willis ring can be fully exposed, and the visual field is direct. The median part, the ipsilateral parasellar and some contralateral structures are fully exposed. The length of the posterior communicating artery and the perforating artery could be clearly observed through the third space.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2011
【分類號】：R322
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