【摘要】： 本論文的研究目的:是通過對(duì)鞍區(qū)斷層解剖和神經(jīng)內(nèi)窺鏡下經(jīng)鼻-蝶竇外科入路解剖的比較研究,了解鞍區(qū)區(qū)域內(nèi)重要的解剖定位標(biāo)志和特點(diǎn),臨床上神經(jīng)內(nèi)窺鏡下經(jīng)鼻-蝶竇鞍區(qū)腫瘤切除術(shù)會(huì)有損傷頸內(nèi)動(dòng)脈和海綿竇引起致命性出血以及損傷視神經(jīng)或視交叉導(dǎo)致失明等嚴(yán)重并發(fā)癥發(fā)生的可能,為避免這些并發(fā)癥的發(fā)生,除了提高設(shè)備水平外,熟練掌握神經(jīng)內(nèi)窺鏡下經(jīng)鼻-蝶竇入路解剖具有非常重要的意義。雖然神經(jīng)內(nèi)窺鏡下經(jīng)鼻-蝶竇鞍區(qū)腫瘤切除術(shù)表現(xiàn)出優(yōu)異的特性,但也存在著一些缺點(diǎn),它所提供的是二維圖像,缺乏立體感。鞍區(qū)局部組織斷層解剖則提供了該部位的連續(xù)切片資料,幫助手術(shù)者建立鞍區(qū)立體解剖觀念,了解鞍區(qū)重要結(jié)構(gòu)的三維解剖關(guān)系,對(duì)臨床經(jīng)鼻-蝶竇入路鞍區(qū)腫瘤切除術(shù)具有指導(dǎo)作用。為提高經(jīng)鼻-蝶竇入路切除鞍區(qū)腫瘤的手術(shù)成功率和安全性提供解剖學(xué)依據(jù)。方法:第一部分:取用經(jīng)福爾馬林固定后的成人12例尸頭鞍區(qū)部為實(shí)驗(yàn)材料,步驟:①標(biāo)本脫鈣:所用材料用10%鹽酸浸泡12～20d,直至骨組織可用針刺入時(shí)為止;②沖洗:取出標(biāo)本,用循環(huán)水沖洗24h;③常規(guī)脫水:將標(biāo)本逐級(jí)脫水,直到標(biāo)本變硬為止;④浸膠:將脫水后的標(biāo)本塊先浸入5%火棉膠中,在真空干燥箱內(nèi)以66kPa的壓力抽真空30min,靜置1天后,再抽真空,再靜置1天后浸入8%火棉膠中;以同樣條件抽真空2次。⑤包埋與制塊:用15%火棉膠作為包埋劑,包埋塊的形成約15～30d。將包埋塊置入70%酒精中硬化保存;⑥焊塊與切片:采用德國酒浸L型切片機(jī)制備切片,對(duì)標(biāo)本進(jìn)行連續(xù)切片,切片厚度設(shè)置在0.5～1.0mm。第二部分:采用成人尸體頭顱標(biāo)本6例,均經(jīng)10%福爾馬林溶液固定。神經(jīng)內(nèi)窺鏡下模擬經(jīng)鼻-蝶竇手術(shù)入路,使用KARL STORZ神經(jīng)內(nèi)窺鏡系統(tǒng)觀察鼻腔、蝶竇、顱內(nèi)鞍區(qū)解剖學(xué)形態(tài)。記錄并了解手術(shù)區(qū)域中特別是蝶鞍及周圍結(jié)構(gòu)的解剖形態(tài),發(fā)現(xiàn)一些與手術(shù)相關(guān)的重要標(biāo)志性結(jié)構(gòu),并予以測量和分析。結(jié)果:①海綿竇是一個(gè)充滿血液的靜脈通道,分為前下、后上、內(nèi)側(cè)和外側(cè)4個(gè)主要間隙。其中海綿竇后上間隙最大,海綿竇外側(cè)間隙最小。同時(shí),在海綿竇內(nèi)仍可見少量靜脈存在。②海綿竇外側(cè)壁可分為淺、深兩層。淺層即硬腦膜層,較為致密。深層為疏松結(jié)締組織,有動(dòng)眼神經(jīng)、滑車神經(jīng)、眼神經(jīng)和上頜神經(jīng)穿行其中。此外,有77.28%的標(biāo)本在海綿竇外側(cè)壁兩層之間存在靜脈竇;③海綿竇面積等指標(biāo)在冠狀切片由前向后逐漸增大,以垂體前葉中部或垂體柄層面為最大,而后逐漸減小;④蝶竇口是最重要的定位標(biāo)志,蝶竇開口位于上鼻甲后上方的蝶篩隱窩,蝶篩隱窩雖然是恒定存在的結(jié)構(gòu),但形態(tài)變異很大,因而不能作為非�？煽康亩ㄎ唤馄蕵�(biāo)志;⑤蝶竇中隔多數(shù)不在中線而偏于一側(cè),且多偏于左側(cè),故蝶竇中隔不能作為經(jīng)鼻-蝶竇入路鞍區(qū)腫瘤切除術(shù)定中線的標(biāo)志;⑥初步證實(shí)蝶鞍一側(cè)或兩側(cè)的缺失區(qū)或薄弱區(qū)可以作為鞍區(qū)腫瘤從鞍區(qū)至鞍旁區(qū)發(fā)展的通道,海綿竇內(nèi)側(cè)壁薄弱甚至缺如是垂體腺瘤侵犯海綿竇的解剖學(xué)基礎(chǔ)。結(jié)論:鞍區(qū)局部組織火棉膠包埋法的連續(xù)斷層切片提供了該部位的連續(xù)切片解剖資料,對(duì)臨床經(jīng)鼻-蝶竇入路鞍區(qū)腫瘤切除術(shù)具有指導(dǎo)作用。經(jīng)鼻-蝶竇入路時(shí)神經(jīng)內(nèi)窺鏡可以提供一個(gè)全景的術(shù)野,可較好地顯露蝶竇、鞍區(qū)顱底區(qū)域。內(nèi)窺鏡下經(jīng)鼻-蝶竇入路從解剖學(xué)角度可以處理大部分以往必須經(jīng)顱手術(shù)的鞍區(qū)病變。此入路的優(yōu)點(diǎn)是不開顱,避免了牽拉腦組織和對(duì)神經(jīng)、血管等結(jié)構(gòu)的手術(shù)副損傷。對(duì)于手術(shù)中保護(hù)重要神經(jīng)、血管結(jié)構(gòu)意義重大。
[Abstract]:The purpose of this paper is to study the important anatomical location markers and features in the area of the saddle area by a comparative study of the anatomy of the sellar area and the transnasal-butterfly surgical approach in the area of the saddle area. In the clinical neuroendoscope, the resection of the nasal-butterfly saddle area can damage the fatal bleeding caused by the internal carotid artery and the sponge, and the occurrence of serious complications such as blindness caused by the injury of the optic nerve or the visual cross can be avoided, so as to avoid the occurrence of the complications, besides the improvement of the equipment level, It is of great significance to master the anatomy of the transsphenoidal approach under the neuroendoscope. Although the resection of the nasal-butterfly saddle area under the neuroendoscope shows excellent characteristics, there are some disadvantages, which provide two-dimensional images and lack of three-dimensional effect. The anatomy of the local tissue of the saddle area provides the continuous slice data of the part, which can help the operator to set up the three-dimensional anatomical concept of the saddle area, and to know the three-dimensional anatomical relation of the important structure of the saddle area, and has the guiding function for the clinical transsphenoidal approach to the tumor resection of the saddle area. In order to improve the surgical success rate and safety of the transsphenoidal approach to the removal of the tumor of the saddle area, the anatomical basis is provided. Methods: The first part: 12 cases of adult cadaver head with formalin fixation were used as the experimental material. The following steps were as follows: the material used for removing calcium: the used material was soaked in 10% hydrochloric acid for 12-20d until the bone tissue can be used for acupuncture, and then rinse: take out the specimen and wash the specimen with the circulating water for 24h; the method comprises the following steps of: carrying out conventional dehydration on the specimen until the specimen is hardened; soaking the specimen until the specimen is hard; soaking the dehydrated specimen in a 5% collodion, pumping for 30min in a vacuum drying oven at a pressure of 66kPa, standing for 1 day, vacuum-pumping, standing for 1 day, and then soaking in 8% of the collodion; the vacuum was evacuated twice under the same conditions. the embedding and the making of the block: 15% of the collodion is used as the embedding agent, and the embedding block is formed in the form of about 15 to 30d. The embedded block was put into 70% alcohol to be hardened and stored; the welding block and the slice: the section was prepared by using the German wine-immersed L-type microtome, and the specimen was continuously sectioned, and the thickness of the section was set to 0.5 ~ 1.0mm. The second part: 6 cases of head specimens of adult cadavers were fixed by 10% formalin. The anatomy of the nasal cavity, the butterfly valve and the intracranial saddle area was observed by using the KARL STORZ neuroendoscope system. The anatomy of the surgical area, in particular the sella and the surrounding structure, was recorded and understood, and some important landmark structures associated with the procedure were identified and measured and analyzed. Results: The sponge sponge is a venous channel filled with blood, divided into four main gaps, namely, front, back, medial and lateral. wherein the gap between the sponge and the sponge is the largest, and the clearance of the outer side of the sponge is the smallest. At the same time, a small number of veins were still visible in the sponge. The outer side wall of the sponge sponge can be divided into a shallow and a deep layer. The superficial layer, the dura mater, is relatively dense. The deep layer is loose connective tissue, with a moving-eye nerve, a sliding vehicle nerve, a eye and a maxillary nerve. In addition, 77. 28% of the specimens had a venous connection between the two layers of the outer side wall of the sponge; the index of the area of the sponge and the sponge gradually increased from the front to the back in the coronal section, at the middle of the anterior lobe of the pituitary or the pituitary stalk, and then gradually decreased; the first butterfly port was the most important positioning mark, the sphenoidal opening is located above the upper part of the upper part of the upper part of the upper part of the upper part of the upper part of the upper part of the upper part of the upper part of the butterfly screen, Therefore, the septum of the butterfly valve can not be used as a marker of the midline of the tumor resection in the saddle area through the nasal-butterfly approach, and the defect area or the weak area on one side or both sides of the sella can be preliminarily confirmed as a channel that can be developed from the saddle area to the saddle side area as a saddle area tumor, The inner side wall of the sponge is weak or even absent, such as the anatomical basis of the pituitary adenoma invading the sponge. Conclusion: The continuous slice section of the local tissue fire-tissue embedding method in the saddle area provides the continuous slice anatomical data of the site, and has a guiding role in the clinical transsphenoidal approach to the tumor resection of the saddle area. Through the nasal-butterfly approach, the neuroendoscope can provide a panoramic field of operation, which can better reveal the area of the skull base of the butterfly and the saddle area. The endoscopic transsphenoidal approach can be used to deal with most of the disease of the saddle area that has to be undergone the operation of the cranium. The method has the advantages of no craniotomy, and avoids the operation of pulling the brain tissue and the operation of the structures such as the nerves, the blood vessels and the like. The vascular structure is of great significance for the protection of important nerves in the operation.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2008
【分類號(hào)】：R322.8-3;R730.5

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