發(fā)布時間：2018-01-27 00:22

  本文關(guān)鍵詞： 顱底內(nèi)鏡 側(cè)顱底腫瘤 唇下 上頜竇 入路　出處：《北京協(xié)和醫(yī)學(xué)院》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：目的隨著手術(shù)技術(shù)的不斷提高和輔助設(shè)備的日益完善,內(nèi)鏡手術(shù)作為切除顱底中線區(qū)腫瘤的重要手段已獲得廣泛認(rèn)可。不僅如此,顱底內(nèi)鏡手術(shù)范圍現(xiàn)正在向側(cè)顱底延伸,但目前還僅局限于經(jīng)鼻入路,而鼻腔結(jié)構(gòu)毀損嚴(yán)重、并發(fā)癥繁多以及側(cè)顱底外側(cè)區(qū)顯露受限等是這一入路致命的缺點。結(jié)合基礎(chǔ)解剖研究和臨床實踐探索,我們嘗試應(yīng)用經(jīng)唇下上頜竇入路內(nèi)鏡手術(shù)切除側(cè)顱底腫瘤,探討該入路個性化的手術(shù)適應(yīng)證、手術(shù)方法、利弊得失及其可能的拓展、演變,以期規(guī)避上述缺點。方法2014年10月至2016年12月間,嘗試經(jīng)唇下上頜竇入路內(nèi)鏡手術(shù)切除9例側(cè)顱底腫瘤,統(tǒng)計每例手術(shù)上頜竇前壁開窗面積、術(shù)中出血量、病灶切除率、手術(shù)時間、并發(fā)癥、隨訪效果,并對每一例手術(shù)計劃的個性化設(shè)計剪裁、具體手術(shù)操作的要點、調(diào)適以及該入路可能的聯(lián)合策略及其拓展演變逐一進(jìn)行探討。結(jié)果所有病例一般狀況良好,KPS評分70分以上。所有病例腫瘤均累及翼腭窩,侵及顳下窩5例,侵入顱內(nèi)中顱窩底4例。上頜竇開窗面積2.5×1.5cm2-3×2.5cm2,平均5.11cm2。瘤體體積為4.14—182.7cm3,平均54.2cm3。MRI增強掃描:除1例囊性腫物外,所有病例腫瘤明顯強化,提示血供豐富,與術(shù)中所見基本相符。手術(shù)時間80—428min,平均210min;出血量100-2500ml,平均717ml;除1例非何杰金氏淋巴瘤因包裹頸內(nèi)動脈、海綿竇內(nèi)多組顱神經(jīng)而予近全切除外,其余病例術(shù)程順利。術(shù)后影像學(xué)復(fù)查顯示:8例腫瘤全切,1例近全切;病理:神經(jīng)鞘瘤5例,惡性神經(jīng)纖維性腫瘤1例,表皮樣囊腫1例,非霍奇金淋巴瘤1例,脊索瘤1例。隨訪3-26個月,平均9.7個月,無復(fù)發(fā)與死亡病例,所有患者均有不同程度的術(shù)側(cè)面部麻木。結(jié)論相較經(jīng)鼻入路,經(jīng)唇下上頜竇前壁入路內(nèi)鏡手術(shù)暴露側(cè)顱底翼腭窩、顳下窩腫瘤路徑最短、角度更直接、操作更靈便,稍加拓展便可顯著增加外側(cè)顳下窩的術(shù)野顯露和操作空間,且完全避免了鼻內(nèi)并發(fā)癥,不失為側(cè)顱底腫瘤內(nèi)鏡治療較為理想的手術(shù)入路;若再巧妙聯(lián)合經(jīng)典的經(jīng)鼻入路,則幾可實現(xiàn)全顱底腫瘤內(nèi)鏡手術(shù)全覆蓋。
[Abstract]:Objective with the continuous improvement of surgical techniques and the improvement of auxiliary equipment, endoscopic surgery as an important means of removing tumors in the midline of the skull base has been widely recognized. Endoscopic skull base surgery is extending to the lateral skull base, but at present it is limited to transnasal approach, and the nasal cavity structure is severely damaged. Multiple complications and limited exposure of the lateral base of the skull are fatal shortcomings of this approach. Combined with basic anatomical research and clinical practice exploration. We try to use translabial maxillary sinus endoscope to remove lateral skull base tumor, and discuss the indication, operative method, advantages and disadvantages, possible expansion and evolution of this approach. Methods from October 2014 to December 2016, 9 cases of lateral skull base tumors were resected by endoscope through sublabial maxillary sinus, and the area of fenestration of anterior wall of maxillary sinus was counted. Intraoperative bleeding volume, focal resection rate, operative time, complications, follow-up results, and for each case of personalized design of the operation plan tailoring, the key points of the specific operation. The adjustment and the possible joint strategy and the development of the approach were discussed one by one. Results all cases were in good condition and KPS score was more than 70. The pterygopalatine fossa was involved in all cases. There were 5 cases of infratemporal fossa and 4 cases of infratemporal fossa. The fenestration area of maxillary sinus was 2.5 脳 1.5 cm ~ (-3) 脳 2.5 cm ~ (2). The mean volume of tumor was 4.14-182.7cm ~ (-3), the average value was 54.2 cm ~ (3). MRI enhanced scan: all the tumors except one cystic tumor were obviously enhanced. The results showed that the blood supply was abundant, which was consistent with the intraoperative findings. The operative time was 80-428 mins with an average of 210 mins. The blood loss was 100-2500ml (mean 717ml); Except for one case of non-Hodgkin 's lymphoma which was wrapped in the internal carotid artery, except for multiple groups of cranial nerves in cavernous sinus, the procedure of operation was smooth. Pathology: schwannoma in 5 cases, malignant nerve fiber tumor in 1 case, epidermoid cyst in 1 case, non-Hodgkin 's lymphoma in 1 case, chordoma in 1 case. There was no recurrence or death, all patients had different degrees of lateral numbness. Conclusion compared with the nasal approach, the lateral pterygopalatine fossa was exposed by endoscope through the anterior wall of the maxillary sinus under the lip, and the tumor path of the subtemporal fossa was the shortest. Angle is more direct, easy to operate, a little expansion can significantly increase the lateral infratemporal fossa of the surgical field exposure and operation space, and completely avoid intranasal complications. It is an ideal approach for endoscopic treatment of lateral skull base tumors. If combined with classical transnasal approach skillfully, the whole skull base tumor can be completely covered by endoscopic surgery.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R739.4

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