本文選題：經(jīng)蝶手術(shù) + 神經(jīng)外科�。� 參考：《第一軍醫(yī)大學(xué)》2007年博士論文

【摘要】： 鞍區(qū)位于顱底中線處，是整個顱腔的中心位置，它包含垂體、兩側(cè)海綿竇(CS)、頸內(nèi)動脈和Ⅲ～Ⅵ對顱神經(jīng)等眾多重要的解剖結(jié)構(gòu)，幾個世紀以來一直是神經(jīng)外科醫(yī)師和神經(jīng)解剖學(xué)者不斷研究的重要區(qū)域。對于該區(qū)域病變的手術(shù)治療，尤其是向兩側(cè)鞍旁擴展并侵犯CS的病變，往往讓神經(jīng)外科醫(yī)生望洋興嘆。而臨床上，合并鞍旁擴展的巨大垂體腺瘤屢見不鮮，傳統(tǒng)通過經(jīng)顱手術(shù)處理該類病變時，往往由于重要的神經(jīng)血管阻擋而無法達到滿意的手術(shù)效果；近年來隨著經(jīng)蝶手術(shù)技巧的完善和手術(shù)器械的發(fā)展，使得經(jīng)蝶手術(shù)由于距離短、創(chuàng)傷小和時間短等優(yōu)點，而被廣泛應(yīng)用于垂體腺瘤的手術(shù)切除。更有學(xué)者通過擴展的經(jīng)蝶入路來處理鞍旁、鞍上和上斜坡處的病變。而對于處理向兩側(cè)擴展的垂體腺瘤時，由于從內(nèi)側(cè)入路不存在各顱神經(jīng)的阻擋，具有經(jīng)顱手術(shù)無法比擬的優(yōu)勢，故如何能很好的利用經(jīng)蝶手術(shù)宋處理該類病變具有重要意義。復(fù)習(xí)文獻發(fā)現(xiàn)目前對于鞍區(qū)的解剖更多的是基于經(jīng)顱手術(shù)視角，而對于經(jīng)蝶手術(shù)下垂體、兩側(cè)CS和眾多神經(jīng)血管結(jié)構(gòu)的解剖學(xué)形態(tài)未有詳細和完善的報道，且對于該區(qū)域的解剖尚存在很多爭論和理解誤區(qū)，正基于此，本研究通過組織學(xué)切片和顯微解剖兩種方法，對胎兒和成人尸頭進行形態(tài)學(xué)研究，并結(jié)合臨床相關(guān)疾病，，探討鞍區(qū)膜性結(jié)構(gòu)和神經(jīng)血管結(jié)構(gòu)等的走形、分布和相互關(guān)系，以期為臨床通過經(jīng)蝶手術(shù)處理該區(qū)域病變提供組織學(xué)和解剖學(xué)依據(jù)。 【目的】 1、本課題通過組織學(xué)切片和顯微解剖的方法，系統(tǒng)的進行了經(jīng)蝶入路下CS的解剖研究，并和傳統(tǒng)的經(jīng)顱入路對該區(qū)域的解剖學(xué)研究進行比較，對該區(qū)域解剖學(xué)系統(tǒng)化、完善化起到了很好的補充作用； 2、由于經(jīng)蝶入路和經(jīng)顱入路的手術(shù)角度，以及術(shù)野范圍的不同，使這兩種入路下垂體窩及兩側(cè)CS區(qū)域的解剖形態(tài)發(fā)生了很大變化，本課題的完成對于經(jīng)蝶入路下該區(qū)解剖結(jié)構(gòu)的變化進行了詳細描述，為使用經(jīng)蝶入路進行CS內(nèi)側(cè)壁手術(shù)操作起到了指導(dǎo)作用； 【方法】 1、經(jīng)蝶海綿竇相關(guān)膜性結(jié)構(gòu)的解剖學(xué)研究 取8例足月引產(chǎn)死胎，小心取出鞍區(qū)、兩側(cè)CS及部分中顱窩底、巖尖部，分別作冠狀和矢狀位連續(xù)切片，層厚8μm，使用常規(guī)HE和Masson’s法染色后，在顯微鏡下仔細觀察鞍內(nèi)和鞍上各層膜性結(jié)構(gòu)的走行關(guān)系，并測量重要解剖區(qū)域的各模型結(jié)構(gòu)的厚度；另取成人固定尸頭標本10例(6男4女)，通過經(jīng)蝶手術(shù)暴露鞍底和CS下壁，逐層切開各層膜性結(jié)構(gòu)，對其走行和分布進行解剖學(xué)研究和測量。 2、經(jīng)蝶海綿竇相關(guān)動脈結(jié)構(gòu)的解剖學(xué)研究 取僅動脈灌注的固定尸頭標本10例20側(cè)(6男4女)，通過經(jīng)蝶手術(shù)暴露鞍旁段頸內(nèi)動脈(PSICA)后，小心分離各動脈分支，對其進行解剖學(xué)描述，并和經(jīng)顱手術(shù)中CS內(nèi)血管結(jié)構(gòu)進行對比研究。 3、經(jīng)蝶海綿竇相關(guān)靜脈結(jié)構(gòu)的解剖學(xué)研究 在胎兒標本中，取前、下、后海綿間竇和基底竇相關(guān)序列10張切片中的4張分別用常規(guī)HE和Masson's染色法染色，其結(jié)果在顯微鏡下觀察。另取血管灌注的尸頭標本10例(動脈和靜脈分別灌注紅色和藍色乳膠)，通過經(jīng)蝶入路暴露鞍底硬膜和CS下壁，切開二者后，確定前、下海綿間竇在鞍底的相對位置。對比經(jīng)顱手術(shù)入路解剖，對CS各靜脈腔隙進行觀察和測量，分析在經(jīng)蝶入路下可利用的靜脈空間。 【結(jié)果】 1、垂體表面有兩層膜性結(jié)構(gòu)覆蓋：垂體固有膜和垂體囊，垂體囊的外側(cè)部又構(gòu)成了CS的內(nèi)側(cè)壁，該壁的下半部較之上半部為厚，其厚度甚至超過CS上壁和鞍隔，而其又可分為兩層：纖維層和硬膜層。該纖維層還構(gòu)成了CS各壁的內(nèi)層，并且包繞在竇內(nèi)各神經(jīng)血管的鞘膜外，CS內(nèi)側(cè)壁的硬膜層向鞍隔孔附近延續(xù)并參與鞍隔的構(gòu)成；而鞍上蛛網(wǎng)膜和軟腦膜在視交叉腹側(cè)、垂體柄上端處融合，并向下和垂體固有膜相延續(xù)。固有膜與垂體表面緊密聯(lián)系，并深入垂體實質(zhì)內(nèi)，從而鞍上蛛網(wǎng)膜下腔在垂體柄處中止； 2、經(jīng)蝶入路下，頸內(nèi)動脈可分為鞍旁段頸內(nèi)動脈(PSICA)和斜坡旁段頸內(nèi)動脈(PCICA)，對于PSICA根據(jù)其形態(tài)可分為上、下水平部和垂直部。而腦膜垂體干源于PSICA下水平部末段內(nèi)壁的9側(cè)(45％)、頂壁4側(cè)(20％)、外壁5側(cè)(25％)、上水平部中段內(nèi)壁2側(cè)(10％)；海綿竇下動脈源于PSICA垂直部中段外壁16側(cè)(80％)，下水平部中段1側(cè)(5％)；另3側(cè)(15％)源于腦膜垂體干；僅在5側(cè)標本(25％)中發(fā)現(xiàn)McConnell's背囊動脈，其源于垂直部上段的內(nèi)壁上，口徑細小(0.85±0.21mm)； 3、所有胎兒標本的組織切片上，均發(fā)現(xiàn)在鞍結(jié)節(jié)下緣、腺垂體下方和鞍背處，均可見垂體囊和鞍底硬膜分離，從而形成了前、下和后海綿間竇；而在鞍背和上斜坡處，雙層硬膜結(jié)構(gòu)分離形成了基底竇。在10例尸體標本的顯微解剖中，4例(40％)可見明顯的前海綿間竇，5例(50％)有下海綿間竇，前海綿間竇位于視神經(jīng)隆突下方，而下海綿間竇位于鞍底隆突向斜坡壓跡轉(zhuǎn)折處。CS分為內(nèi)側(cè)、下外側(cè)和背外側(cè)靜脈腔，內(nèi)側(cè)和下外側(cè)腔在經(jīng)蝶手術(shù)中能方便使用，但背側(cè)腔由于鞍旁段頸內(nèi)動脈上水平部的阻擋，對經(jīng)蝶入路影響較大�！窘Y(jié)論】 1、由于CS內(nèi)側(cè)壁的結(jié)構(gòu)特點，垂體腺瘤最易從囊上壁和上外側(cè)壁向CS突出，包繞頸內(nèi)動脈。在腺瘤向CS內(nèi)膨脹生長的過程中，其間的膜性結(jié)構(gòu)(垂體囊和固有膜)會發(fā)生適形性變化，使得腫瘤和CS之間保持毗鄰關(guān)系，使得在垂體囊和固有膜之間存在一經(jīng)蝶處理巨大垂體腺瘤的安全外科界線。而鞍隔孔附近膜性結(jié)構(gòu)的生理或病理缺陷可能是空蝶鞍綜合癥的發(fā)病機制。 2、經(jīng)蝶入路處理CS內(nèi)側(cè)壁相關(guān)病變時，在PSICA各分支中，垂體下動脈、McConnell's背囊動脈和手術(shù)關(guān)系最密切，是術(shù)中動脈出血的主要原因。同時由于腫瘤向外的推擠作用，腦膜垂體干(MHT)和海綿竇下動脈的起源位置也很有可能就暴露在術(shù)野中，從而造成分支或主干的損傷，因此在對靠下后內(nèi)側(cè)的腫瘤進行切除時，動作要輕柔，盡量避免鉗夾。而術(shù)前進行血管造影，做好腫瘤和血管關(guān)系的良好預(yù)判，是術(shù)中防止出血，盡量全切腫瘤成功的關(guān)鍵。 3、經(jīng)蝶入路下，由于手術(shù)空間狹小、位置深在，以及器械難以自由展開等特點，使得腫瘤切除，特別是術(shù)中止血變得非常困難，熟悉前、下海綿間竇在鞍底的解剖位置，明確CS各個靜脈腔隙的形態(tài)特點和解剖結(jié)構(gòu)，并在術(shù)前對病人影像學(xué)資料的仔細研究，對減少術(shù)中靜脈性出血、神經(jīng)血管的保護，以及增加腫瘤切除的安全性是非常有意義的。
[Abstract]:The saddle area, located at the middle of the skull base, is the central position of the whole skull. It contains many important anatomical structures, such as the pituitary, the bilateral cavernous sinus (CS), the internal carotid artery and the cranial nerves, which have been an important area for neurosurgeons and neuroanatomies for centuries. The surgical treatment of the lesions in this area is especially important. It is a disease that extends and invade CS on the side of the saddle and often makes neurosurgeons sigh. In clinical, the giant pituitary adenoma with paranella expansion is common. In the traditional way of transcranial surgery, it is often due to important neurovascular obstruction and no satisfactory surgical results. In recent years, with the transsphenoidal hand. The improvement of technique and the development of surgical instruments make transsphenoidal surgery widely used for the resection of pituitary adenomas because of the advantages of short distance, small trauma and short time. More scholars have treated the lesions near the saddle, suprasellar and upper clivus by extended transsphenoidal approach. For the treatment of pituitary adenomas extending to both sides, because of the expansion of the transsphenoidal approach, It is of great significance to use the transsphenoidal surgery song to deal with this kind of disease. It is found that more of the anatomy of the sellar region is based on the cranial operation perspective and the pituitary, both sides CS and many gods for transsphenoidal surgery. There are no detailed and perfect reports on the anatomical morphology of the vascular structure, and there are still a lot of controversy and misunderstanding about the anatomy of the region. It is based on this. In this study, the morphological study of fetal and adult cadavers was carried out by two methods of histological section and microdissection, and the membrane structure of the saddle region was discussed in combination with the clinical related diseases. In order to provide histological and anatomical basis for transsphenoidal surgery to treat lesions in this region, the distribution, relationship and distribution of neurovascular structures were discussed.
[Objective]
1, by means of histological section and microdissection, the anatomical study of CS under the transsphenoidal approach is carried out systematically and compared with the traditional transcranial approach to the anatomical study of the region, which is a good supplement for the systematization and perfection of this area.
2, due to the surgical angle of transsphenoidal approach and transcranial approach, as well as the differences in the scope of the operation, the anatomical morphology of the pituitary fossa and both sides of the CS region has been changed greatly in these two approaches, and the changes of the anatomical structure of the area under the transsphenoidal approach are described in detail, and the operation of the medial wall of the CS is performed by transsphenoidal approach. It has played a guiding role.
[method]
1, the anatomy of the cavernous sinus related membrane structures.
8 cases of full term induced abortion were taken to take out the saddle area carefully, both sides of CS and the bottom of the middle cranial fossa, the tip of the rock, respectively, the coronal and sagittal sections were sectioned and the thickness of the layer was 8 mu. After the routine HE and Masson 's staining, the relationship between the membranous structures of the suprasellar and suprasellar layers was carefully observed under the microscope, and the model structures of the important anatomical regions were measured. In addition, 10 adult cadaver specimens (6 men and 4 women) were exposed to the sella fundus and the lower CS wall through transsphenoidal surgery, and the membrane structures were cut by layer by layer, and their walking and distribution were anatomically studied and measured.
2, the anatomy of the transsphenoidal sinus related artery.
20 sides (6 men and 4 women) of fixed cadaver head specimens perfused with only arterial perfusion were carefully separated from the branches of the arteries after transsphenoidal exposure to the internal carotid artery (PSICA) of the sellar segment (PSICA), and the vascular structures in CS were compared with those in the craniotomy.
3, the anatomy of the transsphenoidal sinus related veins.
In the fetal specimens, 4 of the 10 slices of the related sequence of the inter cavernous sinus and the basilar sinus of Houhai were stained with conventional HE and Masson's staining. The results were observed under the microscope. Another 10 cadaver specimens perfused with blood vessels (arteries and veins were perfused with red and blue latex respectively) were exposed to the dural and CS of the saddle base through transsphenoidal approach. The relative position of the anterior and lower cavernous sinus in the saddle base was determined after the incision of the two sides. The venous lacunae of CS were observed and measured in contrast to the transcranial approach, and the venous space available under the transsphenoidal approach was analyzed.
[results]
1, the surface of the pituitary is covered with two layers of membranous structure: the hypophysis propria and the hypophyseal capsule, the lateral part of the hypophysis and the medial wall of the CS. The lower part of the wall is thicker than the upper half of the wall. The thickness of the wall is even more than the upper and saddle septum of the CS, and it can be divided into two layers: the fibrous layer and the dura layer. The fiber layer also forms the inner layer of the CS walls, and the package is wrapped. Outside the sheath of the nerve vessels in the sinus, the dural layer of the medial wall of the CS extends to the saddle septum and participates in the saddle septum, while the suprasellar arachnoid and the pia are fused at the intercruciate ventral side, the upper end of the pituitary stalk, and downward to the hypophyseal propria. The propria is closely linked to the pituitary surface and is deep in the pituitary parenchyma, thus saddle up. The subarachnoid cavity is discontinued at the pituitary stalk;
2, under the transsphenoidal approach, the internal carotid artery can be divided into the lateral saddle segment of the internal carotid artery (PSICA) and the lateral segment of the jugular artery (PCICA). For PSICA, it can be divided into upper, lower and vertical parts according to its morphology. The meningeal pituitary stem is derived from 9 sides (45%) of the inner wall of the end of the horizontal part of PSICA, the top wall of the wall (20%), the 5 side (25%) of the outer wall, and the 2 side of the middle segment of the upper level. 10%): the inferior cavernous sinus artery was derived from 16 sides of the outer wall of the middle part of the PSICA vertical part (80%), 1 sides of the middle segment of the horizontal part of the water (5%), and the other 3 sides (15%) originated from the meningeal hypophysis. Only the McConnell's dorsal capsule artery was found in the 5 side specimens (25%), which originated from the inner wall of the upper vertical part, and the diameter was fine (0.85 0.21mm).
3, on the tissue section of all fetal specimens, they were found in the lower margin of the saddle nodule, below the pituitary gland and the saddle back, and the hypophysis sac and the dura were separated from the saddle base, thus forming the anterior, lower and Houhai cavernous sinuses; and the basal sinus was separated from the double dura structure at the saddle back and the upper slope. In the microanatomy of 10 cadavers, 4 cases (40%) In 5 cases (50%), 5 cases (50%) have inferior cavernous sinus, and the cavernous sinus of Qianhai is located under the protuberance of the optic nerve. The inferior cavernous sinus is located in the medial, lower lateral and lateral vena cava at the turning point of the saddle bottom to the ramp, and the medial and lower lateral cavity can be easily used during transsphenoidal operation, but the dorsal cavity is due to the lateral saddle segment of the neck. The obstruction of the horizontal artery has great influence on the transsphenoidal approach.
1, due to the structural characteristics of the medial wall of the CS, pituitary adenomas are most likely to protruding from the upper and upper lateral walls of the capsule to the internal carotid artery. In the course of the expansion of the adenoma to CS, the membranous structure (the pituitary capsule and propria) changes conformable between the tumor and the CS, making the tumor and the CS adjacent to the hypophyseal capsule and the propria. There is a safe surgical boundary between the transsphenoidal treatment of giant pituitary adenomas, and the physiological or pathological defects of the membranous structure near the sella septum may be the pathogenesis of sella syndrome.
2, when transsphenoidal approach to CS medial wall related lesions, in the branches of the PSICA, the inferior hypophyseal artery, the McConnell's dorsal sac artery and the operation are most closely related, which are the main causes of intraoperative arterial hemorrhage. At the same time, the origin of the meningohypophysis (MHT) and the inferior cavernous sinus artery may also be exposed to the surgical field due to the external extrusion of the tumor. In this way, it causes the injury of the branch or the trunk, so when the tumor is removed, the action should be gentle and try to avoid the clamp. The key to prevent bleeding during the operation and to complete the success of the tumor is to do a good preoperative angiography and a good prediction of the relationship between the tumor and the blood vessel.
3, under the transsphenoidal approach, the resection of the tumor, especially the hemostasis in the operation, is very difficult because of the narrow space of the operation, the deep location and the difficulty of the free expansion of the instruments. The anatomical position of the cavernous sinus in the CS and the anatomical structure of the various venous lacunae is clear, and the imaging data of the patients before the operation are made. Careful study is of great significance in reducing intraoperative venous bleeding, neurovascular protection, and increasing the safety of tumor resection.
【學(xué)位授予單位】：第一軍醫(yī)大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2007
【分類號】：R651;R322

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