乙狀竇前經(jīng)顳骨巖部鎖孔入路的顯微解剖學(xué)研究
發(fā)布時間：2018-07-15 22:08
【摘要】： 第一部分乙狀竇前迷路后鎖孔手術(shù)入路設(shè)計的顯微解剖學(xué)研究 目的:遵循微創(chuàng)化的原則,將微創(chuàng)鎖孔手術(shù)理念融入乙狀竇前入路,探討乙狀竇前迷路后鎖孔手術(shù)的可行性和手術(shù)入路設(shè)計,觀察顯露的解剖結(jié)構(gòu),為臨床應(yīng)用提供依據(jù)。 方法:采用8具經(jīng)福爾馬林固定、顱內(nèi)動靜脈分別用彩色乳膠灌注的尸體頭顱標(biāo)本。按照“盡量小、足夠大”的原則,在傳統(tǒng)乙狀竇前經(jīng)顳骨巖部入路切口的基礎(chǔ)上,探索性地逐步縮小皮膚切口,最后形成耳后“C”形長度約7cm的頭皮切口。分別向前翻開皮瓣和肌筋膜瓣,磨除部分乳突再聯(lián)合顳部開顱,形成大小約3.5cm×3cm的豌豆形骨窗;打開乙狀竇前和顳部硬腦膜,結(jié)扎、切斷巖上竇,牽開顳葉和小腦半球,顯微鏡下觀察所顯露的解剖結(jié)構(gòu)。 結(jié)果:耳后7cm“C”形頭皮切口和3.5cm×3cm大小的骨窗完全可以滿足入路相關(guān)重要結(jié)構(gòu)的顯露。通過調(diào)整頭位和顯微鏡角度,乙狀竇前迷路后鎖孔入路可顯露同側(cè)動眼神經(jīng)、滑車神經(jīng)、三叉神經(jīng)、面聽神經(jīng)復(fù)合體、舌咽神經(jīng)、迷走神經(jīng)、后交通動脈、大腦后動脈、小腦上動脈、小腦前下動脈、基底動脈中上段、上斜坡、橋腦腹外側(cè)面、海綿竇后部結(jié)構(gòu)。 結(jié)論:實驗設(shè)計的乙狀竇前迷路后鎖孔入路具有臨床應(yīng)用可行性,可很好地顯露上述結(jié)構(gòu)。理論上,通過該鎖孔入路可進(jìn)行橋腦腹外側(cè)腫瘤、單側(cè)橋腦海綿狀血管瘤、局限的上巖斜區(qū)腦膜瘤、未侵及內(nèi)耳道的聽神經(jīng)瘤、基底動脈中上段動脈瘤等手術(shù)。 第二部分神經(jīng)導(dǎo)航輔助乙狀竇前經(jīng)迷路鎖孔入路的解剖學(xué)研究 目的:將微創(chuàng)鎖孔手術(shù)理念融入乙狀竇前入路,在神經(jīng)導(dǎo)航輔助下,設(shè)計乙狀竇前經(jīng)迷路鎖孔入路(包括經(jīng)部分迷路及巖尖鎖孔入路和經(jīng)全迷路鎖孔入路兩種手術(shù)方式),探討精確磨除入路相關(guān)骨質(zhì)結(jié)構(gòu)的可行性,為臨床應(yīng)用提供依據(jù)。 方法:采用8具經(jīng)4%甲醛固定、顱內(nèi)動靜脈乳膠灌注的成人尸頭,實驗前建立術(shù)中導(dǎo)航資料。在導(dǎo)航系統(tǒng)中用不同顏色標(biāo)出乙狀竇、骨迷路、內(nèi)耳道等重要結(jié)構(gòu)的范圍。采用迷路后鎖孔入路的切口和骨窗,分層向前翻開皮瓣和肌筋膜瓣,導(dǎo)航下輪廓化乙狀竇、骨半規(guī)管、面神經(jīng)管,依次磨除部分迷路及巖尖、全部迷路,觀察顯露結(jié)構(gòu)的差異,測量顯露結(jié)構(gòu)的長度、手術(shù)視野和乙狀竇前間隙最大術(shù)野角度。 結(jié)果:1、迷路后鎖孔手術(shù)入路的切口可完全滿足經(jīng)迷路鎖孔入路的要求。2、在術(shù)前規(guī)劃的前提下,神經(jīng)導(dǎo)航可輔助精確完成乙狀竇、骨半規(guī)管的輪廓化和部分迷路及巖尖、內(nèi)耳道上結(jié)節(jié)、全部迷路的磨除,可減少盲目磨除造成的重要結(jié)構(gòu)的誤傷。3、同迷路后鎖孔入路比較,經(jīng)部分迷路及巖尖鎖孔入路可明顯增加斜坡、面神經(jīng)顱內(nèi)段和展神經(jīng)的顯露長度、水平視野和垂直視野、乙狀竇前間隙最大術(shù)野角度(均P0.01)。4、經(jīng)全迷路鎖孔入路中,上述硬膜下結(jié)構(gòu)顯露長度、乙狀竇前間隙最大術(shù)野角度較迷路后鎖孔入路也明顯增加(均P0.01),但同部分迷路及巖尖鎖孔入路比較,差異無統(tǒng)計學(xué)意義(均P0.05)。 結(jié)論:乙狀竇前經(jīng)迷路鎖孔入路具有可行性,可良好顯露巖斜區(qū),符合微創(chuàng)理念。神經(jīng)導(dǎo)航系統(tǒng)可輔助精確完成入路相關(guān)的骨質(zhì)結(jié)構(gòu)磨除。部分迷路及巖尖或全迷路磨除均可改善巖斜區(qū)的顯露。經(jīng)部分迷路及巖尖鎖孔入路可廣泛顯露巖斜區(qū)、橋腦小腦角、小腦幕上區(qū)、橋腦前區(qū)和海綿竇后部III-XI腦神經(jīng)之間的結(jié)構(gòu),且聽力和面神經(jīng)功能得以保留的可能性較高。經(jīng)全迷路鎖孔入路的觀察和操作角度更多,但進(jìn)一步增加的顯露有限,且需犧牲聽力。 第三部分神經(jīng)導(dǎo)航輔助下乙狀竇前經(jīng)顳骨巖部鎖孔入路至巖斜區(qū)的量化研究 目的:在神經(jīng)導(dǎo)航輔助下,定量分析乙狀竇前經(jīng)顳骨巖部鎖孔入路四種手術(shù)方式對巖斜區(qū)顯露的差異,提供臨床應(yīng)用依據(jù)。 方法:將乙狀竇前經(jīng)顳骨巖部鎖孔入路按操作先后順序依次分為四種手術(shù)方式:迷路后鎖孔入路,經(jīng)部分迷路及巖尖鎖孔入路,經(jīng)全迷路鎖孔入路和經(jīng)耳蝸鎖孔入路。采用6具(12側(cè))經(jīng)4%甲醛固定、顱內(nèi)動靜脈乳膠灌注、已建立導(dǎo)航資料的成人尸頭行顯微解剖,依次模擬上述鎖孔入路。運(yùn)用Stryker神經(jīng)導(dǎo)航系統(tǒng)依次測定每種入路的巖斜區(qū)顯露面積和手術(shù)操作自由度,統(tǒng)計學(xué)分析處理。 結(jié)果:1、四種鎖孔入路的巖斜區(qū)顯露面積依次為(93.1±17.6)mm2、(340.1±47.1)mm2、(357.4±56.4)mm2、(377.5±59.4)mm2;迷路后鎖孔入路顯著小于后三種術(shù)式(均P0.01),后三者相互之間無顯著差異(均P0.05)。2、手術(shù)操作自由度依次為(555.1±164.1)mm2、(714.1±203.8)mm2、(847.2±186.7)mm2、(906.8±204.6)mm2;經(jīng)部分迷路及巖尖、經(jīng)全迷路、經(jīng)耳蝸三種鎖孔入路均明顯高于迷路后鎖孔入路(均P0.01),經(jīng)全迷路和經(jīng)耳蝸兩種鎖孔入路均高于經(jīng)部分迷路及巖尖鎖孔入路(均P0.01),但經(jīng)全迷路和經(jīng)耳蝸鎖孔入路之間、經(jīng)部分迷路及巖尖和經(jīng)全迷路鎖孔入路之間均無顯著差異(均P0.05)。 結(jié)論:四種手術(shù)方式的創(chuàng)傷依次增大。迷路后鎖孔入路理論上不損傷聽力和面神經(jīng)功能,其對巖斜區(qū)的顯露相對有限。經(jīng)部分迷路及巖尖鎖孔入路的顯露范圍更廣,且面神經(jīng)功能和聽力得以保留的可能性較高。經(jīng)全迷路鎖孔入路對病變處理更為方便,但并不能進(jìn)一步增加巖斜區(qū)的顯露。經(jīng)耳蝸鎖孔入路也不能進(jìn)一步增加巖斜區(qū)的顯露,但適用于侵及巖段頸內(nèi)動脈的病變的手術(shù)。
[Abstract]:Microsurgical anatomy of the approach of the retrosigmoid posterior keyhole approach
Objective: to follow the principle of minimally invasive surgery, integrate the concept of minimally invasive keyhole surgery into the anterior approach of the sigmoid sinus and explore the feasibility and surgical approach design of the posterior sigmoid labyrinthine keyhole operation, and observe the exposed anatomical structure to provide the basis for clinical application.
Methods: 8 cadaver cranial specimens were perfused with color emulsion by formalin fixation. According to the principle of "small and large enough", the skin incision was gradually reduced on the basis of the traditional incision of the petrous part of the temporal bone before the traditional sigmoid sinus. Finally, the scalp incision with a "C" shaped length of about 7cm after the ear was formed. The flap and the myofascial flap were opened forward, and the part of the mastoid process combined with the temporal craniotomy to form a pea shaped bone window of about 3.5cm x 3cm; open the anterior and temporal dura mater, ligation, cut off the upper sinus, and distraction the temporal and cerebellar hemispheres. Under the microscope, the anatomical structure was observed under the microscope.
Results: the posterior 7cm "C" scalp incision and the 3.5cm x 3cm size bone window can fully meet the exposure of the important structure. By adjusting the head and microscope angles, the anterior labyrinth keyhole approach of the sigmoid sinus can reveal the ipsilateral oculomotor nerve, the trochlear nerve, the trigeminal nerve, the facial nerve complex, the glossopharyngeal nerve, vagus nerve, and the post traffic. The artery, posterior cerebral artery, superior cerebellar artery, anterior inferior cerebellar artery, middle and upper part of the basilar artery, superior slope, lateral ventral surface of the pons, and posterior cavernous sinus.
Conclusion: the experimental design of the anterior labyrinthine keyhole approach is feasible and can reveal the above structure well. In theory, the keyhole approach can be used to carry out the ventral lateral tumor of the bridge brain, the cerebral cavernous angioma of the unilateral bridge, the limited upper diagonal meningioma, the acoustic neuroma of the inner ear canal, the upper middle artery in the basilar artery. Surgery, such as tumor.
The second part is neuronavigation assisted anatomic study of the anterior sigmoid sinus via labyrinthine keyhole approach.
Objective: to integrate the concept of minimally invasive keyhole surgery into the anterior approach of the sigmoid sinus, and to design the anterior trans sigmoid sinus via the labyrinth keyhole approach (including two surgical methods, including the partial labyrinth and the apex keyhole approach and the full labyrinthine keyhole approach) with the aid of neuronavigation, and to explore the feasibility of grinding the related bone structure in the approach to provide the basis for clinical application.
Methods: 8 adult cadavers were perfused with 4% formalin and perfusion of intracranial arteriovenous glue. The navigation data were established before the experiment. In the navigation system, the scope of the important structures such as the sigmoid sinus, the bone labyrinth and the inner ear canal were marked with different colors. The incision and bone window of the labyrinthine keyhole approach were used, the flap and the myofascial flap were opened in stratified forward, and the navigation was guided. The lower wheel profile of the sigmoid sinus, the semicircular canal of the bone, and the facial nerve canal, all the labyrinthine and the tip of the rock, all the labyrinthine, observe the difference of the exposed structure, measure the length of the exposed structure, the operation field of vision and the maximum angle of the operation field in the anterior space of the sigmoid sinus.
Results: 1, the incision of the labyrinth keyhole approach can fully meet the requirement of the labyrinthine keyhole approach.2. On the premise of pre operation planning, the neuronavigation can assist the precise completion of the sigmoid sinus, the contour of the semicircular canal, the part of the labyrinth and the tip of the rock, the upper inner canal nodules, and the grinding of all the fans, which can reduce the important structure caused by blind grinding. .3, compared with the labyrinthine keyhole approach, can obviously increase the slope, the exposure length of the cranial and abduction nerves, the horizontal and vertical horizons, the maximum field angle (P0.01).4 in the anterior space of the sigmoid sinus through partial labyrinthine and apex keyhole approach. The subdural structure shows the length of the subdural structure and the anterior intersigmoid sinus through the full labyrinth keyhole approach. The maximum gap angle was also significantly increased (all P0.01) than that of the labyrinthine keyhole approach, but the difference was not statistically significant (P0.05) compared with the partial labyrinth and the apex keyhole approach.
Conclusion: the anterior sigmoid sinus via the labyrinthine keyhole approach is feasible, and it can well reveal the diagonal area and meet the minimally invasive idea. The neuronavigation system can assist the precise completion of the bone structure grinding. Partial labyrinth, rock tip or full labyrinth grinding can improve the exposure of the diagonal area. The labyrinth and the rock tip keyhole approach can be widely exposed. In the oblique area, the cerebellopontine angle, the supratentorial area of the cerebellar cerebellum, the anterior region of the pontine and the posterior cavernous sinus, the structure of the III-XI brain nerve, and the possibility of retaining the hearing and facial nerve function is higher. The observation and operation of the full labyrinth keyhole approach are more, but the further increase of exposure is limited, and the hearing is sacrificed.
The third part is a quantitative study of neuronavigation assisted anterior petrosal keyhole approach to petroclival region.
Objective: with the aid of neuronavigation, the quantitative analysis of the differences in the exposure of the diagonal region by the four methods of the keyhole approach of the petrous bone before the sigmoid sinus and the petrous bone of the temporal bone is provided.
Methods: according to the sequence of the keyhole entry of the petrous sinus before the sigmoid sinus, it was divided into four surgical methods: the posterior labyrinth keyhole approach, the partial labyrinth and the apex keyhole approach, the total labyrinth keyhole approach and the cochlear keyhole approach. 6 (12 sides) were fixed with 4% formaldehyde and intracranial arteriovenous perfusion was perfused. The navigation data had been established. The human corpse was dissected by microdissection, and the keyhole approach was simulated in turn. Using the Stryker neuronavigation system, the exposed area of the diagonal area and the operation freedom degree were measured and analyzed statistically.
Results: 1, the exposed area of the rocky area of the four keyhole approaches was (93.1 + 17.6) mm2, (340.1 + 47.1) mm2, (357.4 + 56.4) mm2 and (377.5 + 59.4) mm2, and the post labyrinth keyhole approach was significantly smaller than the latter three (all P0.01), and there was no significant difference (all P0.05).2 in the subsequent three, and the operation freedom was in turn (555.1 + 164.1) mm2 and MM 2, (847.2 + 186.7) mm2 and (906.8 + 204.6) mm2, through partial labyrinth and apex, through all labyrinthine and three keyhole approach of cochlea were significantly higher than that of posterior locking keyhole approach (all P0.01). All labyrinthine and cochlear keyhole entry approaches were higher than those of partial labyrinthine and apex keyhole approach (all P0.01), but through all labyrinthine and cochlear keyhole approach, through all labyrinthine and cochlear keyhole approach There was no significant difference in partial labyrinth and petrous apex and total labyrinthine keyhole approach (P0.05).
Conclusion: the trauma of the four modes of operation increased in turn. The theory of the posterior labyrinth keyhole approach does not damage the hearing and facial nerve function, and its exposure to the diagonal area is relatively limited. The exposure to the partial labyrinth and the apex keyhole approach is more extensive, and the possibility of preserving the facial nerve function and hearing is higher. The lesions through the total labyrinth keyhole approach to the lesion The treatment is more convenient, but it can not further increase the exposure of the diagonal area. The approach of the cochlear keyhole approach can not further increase the exposure of the diagonal area, but it is suitable for the operation of the internal carotid artery invasion.
【學(xué)位授予單位】：蘇州大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2007
【分類號】：R651;R322
本文編號：2125532
[Abstract]:Microsurgical anatomy of the approach of the retrosigmoid posterior keyhole approach
Objective: to follow the principle of minimally invasive surgery, integrate the concept of minimally invasive keyhole surgery into the anterior approach of the sigmoid sinus and explore the feasibility and surgical approach design of the posterior sigmoid labyrinthine keyhole operation, and observe the exposed anatomical structure to provide the basis for clinical application.
Methods: 8 cadaver cranial specimens were perfused with color emulsion by formalin fixation. According to the principle of "small and large enough", the skin incision was gradually reduced on the basis of the traditional incision of the petrous part of the temporal bone before the traditional sigmoid sinus. Finally, the scalp incision with a "C" shaped length of about 7cm after the ear was formed. The flap and the myofascial flap were opened forward, and the part of the mastoid process combined with the temporal craniotomy to form a pea shaped bone window of about 3.5cm x 3cm; open the anterior and temporal dura mater, ligation, cut off the upper sinus, and distraction the temporal and cerebellar hemispheres. Under the microscope, the anatomical structure was observed under the microscope.
Results: the posterior 7cm "C" scalp incision and the 3.5cm x 3cm size bone window can fully meet the exposure of the important structure. By adjusting the head and microscope angles, the anterior labyrinth keyhole approach of the sigmoid sinus can reveal the ipsilateral oculomotor nerve, the trochlear nerve, the trigeminal nerve, the facial nerve complex, the glossopharyngeal nerve, vagus nerve, and the post traffic. The artery, posterior cerebral artery, superior cerebellar artery, anterior inferior cerebellar artery, middle and upper part of the basilar artery, superior slope, lateral ventral surface of the pons, and posterior cavernous sinus.
Conclusion: the experimental design of the anterior labyrinthine keyhole approach is feasible and can reveal the above structure well. In theory, the keyhole approach can be used to carry out the ventral lateral tumor of the bridge brain, the cerebral cavernous angioma of the unilateral bridge, the limited upper diagonal meningioma, the acoustic neuroma of the inner ear canal, the upper middle artery in the basilar artery. Surgery, such as tumor.
The second part is neuronavigation assisted anatomic study of the anterior sigmoid sinus via labyrinthine keyhole approach.
Objective: to integrate the concept of minimally invasive keyhole surgery into the anterior approach of the sigmoid sinus, and to design the anterior trans sigmoid sinus via the labyrinth keyhole approach (including two surgical methods, including the partial labyrinth and the apex keyhole approach and the full labyrinthine keyhole approach) with the aid of neuronavigation, and to explore the feasibility of grinding the related bone structure in the approach to provide the basis for clinical application.
Methods: 8 adult cadavers were perfused with 4% formalin and perfusion of intracranial arteriovenous glue. The navigation data were established before the experiment. In the navigation system, the scope of the important structures such as the sigmoid sinus, the bone labyrinth and the inner ear canal were marked with different colors. The incision and bone window of the labyrinthine keyhole approach were used, the flap and the myofascial flap were opened in stratified forward, and the navigation was guided. The lower wheel profile of the sigmoid sinus, the semicircular canal of the bone, and the facial nerve canal, all the labyrinthine and the tip of the rock, all the labyrinthine, observe the difference of the exposed structure, measure the length of the exposed structure, the operation field of vision and the maximum angle of the operation field in the anterior space of the sigmoid sinus.
Results: 1, the incision of the labyrinth keyhole approach can fully meet the requirement of the labyrinthine keyhole approach.2. On the premise of pre operation planning, the neuronavigation can assist the precise completion of the sigmoid sinus, the contour of the semicircular canal, the part of the labyrinth and the tip of the rock, the upper inner canal nodules, and the grinding of all the fans, which can reduce the important structure caused by blind grinding. .3, compared with the labyrinthine keyhole approach, can obviously increase the slope, the exposure length of the cranial and abduction nerves, the horizontal and vertical horizons, the maximum field angle (P0.01).4 in the anterior space of the sigmoid sinus through partial labyrinthine and apex keyhole approach. The subdural structure shows the length of the subdural structure and the anterior intersigmoid sinus through the full labyrinth keyhole approach. The maximum gap angle was also significantly increased (all P0.01) than that of the labyrinthine keyhole approach, but the difference was not statistically significant (P0.05) compared with the partial labyrinth and the apex keyhole approach.
Conclusion: the anterior sigmoid sinus via the labyrinthine keyhole approach is feasible, and it can well reveal the diagonal area and meet the minimally invasive idea. The neuronavigation system can assist the precise completion of the bone structure grinding. Partial labyrinth, rock tip or full labyrinth grinding can improve the exposure of the diagonal area. The labyrinth and the rock tip keyhole approach can be widely exposed. In the oblique area, the cerebellopontine angle, the supratentorial area of the cerebellar cerebellum, the anterior region of the pontine and the posterior cavernous sinus, the structure of the III-XI brain nerve, and the possibility of retaining the hearing and facial nerve function is higher. The observation and operation of the full labyrinth keyhole approach are more, but the further increase of exposure is limited, and the hearing is sacrificed.
The third part is a quantitative study of neuronavigation assisted anterior petrosal keyhole approach to petroclival region.
Objective: with the aid of neuronavigation, the quantitative analysis of the differences in the exposure of the diagonal region by the four methods of the keyhole approach of the petrous bone before the sigmoid sinus and the petrous bone of the temporal bone is provided.
Methods: according to the sequence of the keyhole entry of the petrous sinus before the sigmoid sinus, it was divided into four surgical methods: the posterior labyrinth keyhole approach, the partial labyrinth and the apex keyhole approach, the total labyrinth keyhole approach and the cochlear keyhole approach. 6 (12 sides) were fixed with 4% formaldehyde and intracranial arteriovenous perfusion was perfused. The navigation data had been established. The human corpse was dissected by microdissection, and the keyhole approach was simulated in turn. Using the Stryker neuronavigation system, the exposed area of the diagonal area and the operation freedom degree were measured and analyzed statistically.
Results: 1, the exposed area of the rocky area of the four keyhole approaches was (93.1 + 17.6) mm2, (340.1 + 47.1) mm2, (357.4 + 56.4) mm2 and (377.5 + 59.4) mm2, and the post labyrinth keyhole approach was significantly smaller than the latter three (all P0.01), and there was no significant difference (all P0.05).2 in the subsequent three, and the operation freedom was in turn (555.1 + 164.1) mm2 and MM 2, (847.2 + 186.7) mm2 and (906.8 + 204.6) mm2, through partial labyrinth and apex, through all labyrinthine and three keyhole approach of cochlea were significantly higher than that of posterior locking keyhole approach (all P0.01). All labyrinthine and cochlear keyhole entry approaches were higher than those of partial labyrinthine and apex keyhole approach (all P0.01), but through all labyrinthine and cochlear keyhole approach, through all labyrinthine and cochlear keyhole approach There was no significant difference in partial labyrinth and petrous apex and total labyrinthine keyhole approach (P0.05).
Conclusion: the trauma of the four modes of operation increased in turn. The theory of the posterior labyrinth keyhole approach does not damage the hearing and facial nerve function, and its exposure to the diagonal area is relatively limited. The exposure to the partial labyrinth and the apex keyhole approach is more extensive, and the possibility of preserving the facial nerve function and hearing is higher. The lesions through the total labyrinth keyhole approach to the lesion The treatment is more convenient, but it can not further increase the exposure of the diagonal area. The approach of the cochlear keyhole approach can not further increase the exposure of the diagonal area, but it is suitable for the operation of the internal carotid artery invasion.
【學(xué)位授予單位】：蘇州大學(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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