本文選題：鎖孔手術(shù) + 乙狀竇后入路��； 參考：《蘇州大學(xué)》2009年博士論文

【摘要】： 第一部分乙狀竇后鎖孔入路的顯微解剖學(xué)研究 目的:遵循微創(chuàng)原則,對傳統(tǒng)乙狀竇后入路進(jìn)行鎖孔改良,應(yīng)用神經(jīng)導(dǎo)航系統(tǒng)進(jìn)行尸頭解剖量化評價,探討乙狀竇后鎖孔手術(shù)的可行性,明確其手術(shù)適用范圍,并予臨床初步驗證。 方法:采用6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。首先進(jìn)行乙狀竇后鎖孔入路,然后擴(kuò)大為常規(guī)乙狀竇后入路,觀察顯露的解剖結(jié)構(gòu)差異。以無框架的立體定向?qū)Ш皆O(shè)備測量兩種入路下巖斜區(qū)、腦干的顯露面積和Meckle’s腔、三叉神經(jīng)根、面神經(jīng)根、內(nèi)聽道口、舌咽神經(jīng)根、頸靜脈孔等六個點容許的最大觀察角度,行統(tǒng)計學(xué)分析比較。應(yīng)用乙狀竇后鎖孔入路治療15例小腦橋腦角、巖斜區(qū)和天幕腫瘤患者進(jìn)行臨床驗證,11例腫瘤最長徑大于3.0cm。 結(jié)果:乙狀竇后鎖孔入路與常規(guī)入路的解剖結(jié)構(gòu)顯露相仿,可顯露上至天幕前外側(cè)緣,下近枕骨大孔,內(nèi)側(cè)到橋腦和中腦的前外側(cè)方,通過神經(jīng)間隙可以到達(dá)同側(cè)中上巖斜區(qū)的外2/3,但對巖尖、下斜坡和天幕切跡以上的結(jié)構(gòu)顯露欠佳或不能顯露。乙狀竇后鎖孔入路下巖斜區(qū)、腦干顯露面積分別為304.73±28.93mm2、143.9±31.87mm2,而常規(guī)入路則分別為346.43±42.80mm2、136.05±9.05mm2,兩者在巖斜區(qū)、腦干的顯露面積都沒有統(tǒng)計學(xué)顯著性差異(P0.05)。對于選定的六個靶點,無論垂直還是水平觀察角度,常規(guī)入路都比鎖孔入路的觀察角度大(P0.05)。臨床驗證15例腫瘤手術(shù),13例全切,2例次全切,術(shù)后4例新出現(xiàn)周圍性面癱,其中3例為短暫性的面神經(jīng)麻痹。7例術(shù)前聽力下降的患者,其中5例術(shù)后聽力喪失,1例術(shù)后聽力改善,無其它術(shù)后并發(fā)癥。 結(jié)論:乙狀竇后鎖孔入路與常規(guī)入路具有相似的顯露范圍,可用于小腦橋腦角和巖斜區(qū)的腫瘤、中腦和橋腦前側(cè)方及側(cè)方腫瘤手術(shù),對大型、巨大型腫瘤也可通過分塊切除、瘤內(nèi)減壓的方法,逐步顯露并全切腫瘤。該入路是具有實際臨床應(yīng)用價值的一種簡捷、安全的微創(chuàng)手術(shù)入路。 第二部分枕下正中經(jīng)小腦延髓裂鎖孔入路的顯微解剖學(xué)研究 目的:基于鎖孔原理設(shè)計枕下正中經(jīng)小腦延髓裂鎖孔入路,應(yīng)用神經(jīng)導(dǎo)航系統(tǒng)進(jìn)行尸頭解剖量化評價,探討其可行性和手術(shù)適用范圍,并進(jìn)行初步臨床驗證,為臨床應(yīng)用提供可靠依據(jù)。 方法:采用6具經(jīng)4%福爾馬林固定、顱內(nèi)動靜脈乳膠灌注的成人尸體頭顱標(biāo)本。首先行枕下正中經(jīng)小腦延髓裂鎖孔入路解剖,觀察各個步驟顯露的解剖結(jié)構(gòu),以無框架的立體定向?qū)Ш皆O(shè)備測量鎖孔入路下四腦室底的面積顯露和導(dǎo)水管下口、雙側(cè)側(cè)孔連線與正中溝交點、閂部的觀察角度;再以銑刀銑下寰椎后弓,測量上述參數(shù),測量后將寰椎后弓用鈦片和鈦釘復(fù)位;然后延長切口、擴(kuò)大骨窗成常規(guī)入路,測量寰椎后弓去除前后的上述參數(shù);最后行統(tǒng)計學(xué)分析。應(yīng)用枕下正中經(jīng)小腦延髓裂鎖孔入路治療14例四腦室內(nèi)及其周圍區(qū)域的腫瘤,包括小腦蚓部腫瘤5例(髓母細(xì)胞瘤3例、膠質(zhì)瘤1例,轉(zhuǎn)移癌1例),四腦室內(nèi)病變6例(室管膜瘤4例,蛛網(wǎng)膜囊腫1例,脈絡(luò)膜乳頭狀瘤1例)、腦干背側(cè)病變2例(橋延溝水平海綿狀血管瘤1例,橋腦膠質(zhì)增生1例)、腦干后方機(jī)化血腫1例,進(jìn)行臨床驗證。 結(jié)果:通過調(diào)整頭位和顯微鏡的投射角度,枕下正中鎖孔入路下分離小腦延髓裂后可顯露脈絡(luò)膜、下髓帆,逐步切開脈絡(luò)膜下髓帆可顯露四腦室底、側(cè)隱窩、側(cè)孔及小腦蚓部腦室面。鎖孔入路下對四腦室底的角度顯露不如常規(guī)入路下寬(P0.01),但兩種入路下四腦室底的顯露面積沒有顯著性統(tǒng)計學(xué)差異(P=0.06)。常規(guī)入路下顯露角度的增加,可增加手術(shù)操作的自由度,有利于從多個方向?qū)Π悬c進(jìn)行操作,但并不能增加四腦室底的顯露面積。鎖孔入路下,盡管靶點顯露角度減小,使手術(shù)操作的自由度變小,但不影響靶點的顯露,在鎖孔的深部放大效應(yīng)下,可對相關(guān)靶點進(jìn)行有效操作。去除寰椎后弓不能增加鎖孔入路下四腦室底的顯露面積(P=0.84)。無論常規(guī)入路還是鎖孔入路下磨除寰椎后弓可以增加四腦室底垂直顯露角度(P0.05),但對水平顯露角度沒有影響(P0.05)。本組14例腫瘤均顯微鏡下全切,1例老年患者術(shù)后死于肺部感染,其余13例術(shù)前癥狀改善,未出現(xiàn)腦干和顱神經(jīng)損傷相關(guān)的并發(fā)癥,無“小腦性緘默”等經(jīng)蚓部手術(shù)入路相關(guān)的并發(fā)癥。 結(jié)論:枕下正中經(jīng)小腦延髓裂鎖孔入路與常規(guī)入路具有相似的顯露面積,無需磨除寰椎后弓就能滿意顯露四腦室底結(jié)構(gòu),在掌握鎖孔入路器械操作技術(shù)后,使用長桿狀和槍式器械,通過相對狹小的顯露角度,可以安全、簡捷地進(jìn)行四腦室內(nèi)、橋腦延髓背側(cè)以及小腦下蚓部等部位腫瘤手術(shù),是一種切實可行的微創(chuàng)手術(shù)入路。
[Abstract]:Microanatomy study of retrosigmoid keyhole approach
Objective: to follow the principle of minimally invasive, the traditional posterior approach of the sigmoid sinus is improved, and the neural navigation system is used to evaluate the autopsy, and the feasibility of the post sigmoid keyhole operation is discussed, and the scope of operation is clearly defined and the clinical preliminary verification is given.
Methods: 6 cadaver cranial specimens were perfused with color emulsion by formalin fixation. First, the posterior sigmoid keyhole approach was used, and then extended to the conventional posterior approach of the sigmoid sinus, and the dissected anatomical differences were observed. The exposure of two kinds of diagonal areas under the unframeless stereotactic navigation equipment and the exposure of the brain stem were measured. The maximum observation angle allowed by six points, such as area and Meckle 's cavity, trigeminal root, facial nerve root, inner auditory canal, glossopharyngeal nerve root and jugular hole, was compared. 15 cases of cerebellopontine angle, diagonal area and tentorial tumor were treated by posterior sigmoid keyhole approach, and the longest diameter of 11 cases was greater than 3.0cm..
Results: the posterior sigmoid keyhole approach is similar to the anatomical structure of the conventional approach. It can be exposed to the anterolateral margin of the tentorium, near the occipital big hole, and the medial to the anterior lateral side of the bridge brain and middle brain. Through the nerve gap, the outer 2/3 in the upper and upper diagonal area of the same side can be reached, but the structure above the rock tip, the lower slope and the curtain notch above is poorly exposed or not. The exposed area of the brain stem was 304.73 + 28.93mm2143.9 + 31.87mm2 respectively, while the conventional approach was 346.43 + 42.80mm2136.05 + 9.05mm2 respectively. There was no significant difference in the exposed area of the brain stem (P0.05) in the diagonal area (P0.05). For the selected six targets, whether vertical or water The observation angle of the conventional approach was larger than the observation angle of the keyhole approach (P0.05). Clinical verification of 15 cases of tumor surgery, 13 cases of total resection, 2 total resection, 4 new peripheral facial paralysis after operation, 3 cases of transient facial paralysis in.7 cases with hearing loss before operation, 5 cases of hearing loss after operation, 1 cases of postoperative hearing improvement, no other. Postoperative complications.
Conclusion: the retrosigmoid keyhole approach has a similar exposure range with the conventional approach. It can be used for tumors in the cerebellopontine angle and diagonal area, the anterior lateral and lateral tumors of the middle brain and the bridge brain, and the large and giant tumor can be excised by block resection and the method of intratumoral decompression. A simple and safe minimally invasive surgical approach.
The second part is a microanatomical study of the occipital median cerebellopontine keyhole approach.
Objective: Based on the principle of keyhole, the suboccipital medullary cleft keyhole approach was designed, and the neuronavigation system was used to evaluate the anatomy of the autopsy, and the feasibility and scope of operation were discussed, and preliminary clinical validation was carried out to provide a reliable basis for clinical application.
Methods: 6 adult cadavers were perfused with 4% formalin fixed with intracranial arteriovenous glue. First, the posterior occipital middle cerebellar medullary cleft keyhole approach was performed to observe the dissecting anatomy of each step, and the area of the four ventricle under the keyhole approach and the lower entrance of the aqueduct under the unframeless stereotactic navigation equipment were measured. Both sides of the side of the lateral hole and the middle trench intersection, the observation angle of the latch; then milling the posterior arch of the atlas with the milling cutter and measuring the above parameters, after the measurement, the posterior arch of the atlas is reattached with titanium and titanium nails; then the incision is extended and the bone window is extended to the conventional approach to measure the above parameters before and after the removal of the posterior arch of the atlas; the final statistical analysis. Application of the suboccipital median channel. The cerebellopontine cleft keyhole approach was used to treat 14 cases of four intraventricular and surrounding regions, including 5 cases of vermis of the cerebellum (3 cases of medulloblastoma, 1 cases of glioma, 1 cases of metastatic carcinoma), 6 cases of four intraventricular lesions (4 cases of ependymoma, 1 arachnoid cysts, 1 cases of choroidal papilloma), and 2 cases of lateral cavernous hemangioma of the brainstem (cavernous hemangioma) 1 cases, 1 cases of pontine gliosis, 1 cases of hematoma in the posterior part of the brain stem were clinically verified.
Results: by adjusting the projection angle of the head and microscope, the choroid membrane could be revealed after the cerebellar medullary cleft under the middle occipital keyhole approach, and the lower medullary sails could reveal the bottom of the four ventricle, the lateral recess, the lateral hole and the ventricle of the cerebellum. The angle of the four ventricle under the keyhole approach was not as wide as that of the conventional approach (P0. 01) but there is no significant difference in the exposed area of the four ventricles under the two approaches (P=0.06). The increase of the exposure angle under the conventional approach can increase the degree of freedom of the operation and facilitate the operation of the target in multiple directions, but it does not increase the exposure area of the four ventricle. The degree of freedom of the operation is smaller, but it does not affect the exposure of the target. Under the deep amplification effect of the keyhole, the related target can be operated effectively. The removal of the posterior arch of the atlas can not increase the exposed area of the four ventricle below the keyhole entry (P=0.84). No matter the conventional entry or the locking of the keyhole, the posterior arch of the atlas can increase the bottom of the ventricles of the four ventricle. The direct exposure angle (P0.05) was not affected by the horizontal exposure angle (P0.05). 14 cases of this group were all cut under microscope, 1 cases died of pulmonary infection after operation, the other 13 cases were improved before operation, no complications related to brain stem and cranial nerve injury, no cerebellar mutism and other complications related to vermis operation.
Conclusion: the suboccipital midocerebellar medullary cleft keyhole approach has a similar exposure area to the conventional approach, without the need to wear the posterior arch of the atlas to reveal the four ventricle bottom structure. After mastering the keyhole approach, long rod and gun instruments can be used safely and succinctly in the four ventricle through a relatively narrow exposure angle. Tumor surgery in the dorsal part of the medulla oblongata and the inferior cerebellar vermis is a feasible minimally invasive approach.
【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】：2009
【分類號】：R322

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