摘要
第一部分乙状窦前迷路后锁孔手术入路设计的显微解剖学研究
目的:遵循微创化的原则,将微创锁孔手术理念融入乙状窦前入路,探讨乙状窦前迷路后锁孔手术的可行性和手术入路设计,观察显露的解剖结构,为临床应用提供依据。
方法:采用8具经福尔马林固定、颅内动静脉分别用彩色乳胶灌注的尸体头颅标本。按照“尽量小、足够大”的原则,在传统乙状窦前经颞骨岩部入路切口的基础上,探索性地逐步缩小皮肤切口,最后形成耳后“C”形长度约7cm的头皮切口。分别向前翻开皮瓣和肌筋膜瓣,磨除部分乳突再联合颞部开颅,形成大小约3.5cm×3cm的豌豆形骨窗;打开乙状窦前和颞部硬脑膜,结扎、切断岩上窦,牵开颞叶和小脑半球,显微镜下观察所显露的解剖结构。
结果:耳后7cm“C”形头皮切口和3.5cm×3cm大小的骨窗完全可以满足入路相关重要结构的显露。通过调整头位和显微镜角度,乙状窦前迷路后锁孔入路可显露同侧动眼神经、滑车神经、三叉神经、面听神经复合体、舌咽神经、迷走神经、后交通动脉、大脑后动脉、小脑上动脉、小脑前下动脉、基底动脉中上段、上斜坡、桥脑腹外侧面、海绵窦后部结构。
结论:实验设计的乙状窦前迷路后锁孔入路具有临床应用可行性,可很好地显露上述结构。理论上,通过该锁孔入路可进行桥脑腹外侧肿瘤、单侧桥脑海绵状血管瘤、局限的上岩斜区脑膜瘤、未侵及内耳道的听神经瘤、基底动脉中上段动脉瘤等手术。
第二部分神经导航辅助乙状窦前经迷路锁孔入路的解剖学研究
目的:将微创锁孔手术理念融入乙状窦前入路,在神经导航辅助下,设计乙状窦前经迷路锁孔入路(包括经部分迷路及岩尖锁孔入路和经全迷路锁孔入路两种手术方式),探讨精确磨除入路相关骨质结构的可行性,为临床应用提供依据。
方法:采用8具经4%甲醛固定、颅内动静脉乳胶灌注的成人尸头,实验前建立术中导航资料。在导航系统中用不同颜色标出乙状窦、骨迷路、内耳道等重要结构的范围。采用迷路后锁孔入路的切口和骨窗,分层向前翻开皮瓣和肌筋膜瓣,导航下轮廓化乙状窦、骨半规管、面神经管,依次磨除部分迷路及岩尖、全部迷路,观察显露结构的差异,测量显露结构的长度、手术视野和乙状窦前间隙最大术野角度。
结果:1、迷路后锁孔手术入路的切口可完全满足经迷路锁孔入路的要求。2、在术前规划的前提下,神经导航可辅助精确完成乙状窦、骨半规管的轮廓化和部分迷路及岩尖、内耳道上结节、全部迷路的磨除,可减少盲目磨除造成的重要结构的误伤。3、同迷路后锁孔入路比较,经部分迷路及岩尖锁孔入路可明显增加斜坡、面神经颅内段和展神经的显露长度、水平视野和垂直视野、乙状窦前间隙最大术野角度(均P<0.01)。4、经全迷路锁孔入路中,上述硬膜下结构显露长度、乙状窦前间隙最大术野角度较迷路后锁孔入路也明显增加(均P<0.01),但同部分迷路及岩尖锁孔入路比较,差异无统计学意义(均P>0.05)。
结论:乙状窦前经迷路锁孔入路具有可行性,可良好显露岩斜区,符合微创理念。神经导航系统可辅助精确完成入路相关的骨质结构磨除。部分迷路及岩尖或全迷路磨除均可改善岩斜区的显露。经部分迷路及岩尖锁孔入路可广泛显露岩斜区、桥脑小脑角、小脑幕上区、桥脑前区和海绵窦后部III-XI脑神经之间的结构,且听力和面神经功能得以保留的可能性较高。经全迷路锁孔入路的观察和操作角度更多,但进一步增加的显露有限,且需牺牲听力。
第三部分神经导航辅助下乙状窦前经颞骨岩部锁孔入路至岩斜区的量化研究
目的:在神经导航辅助下,定量分析乙状窦前经颞骨岩部锁孔入路四种手术方式对岩斜区显露的差异,提供临床应用依据。
方法:将乙状窦前经颞骨岩部锁孔入路按操作先后顺序依次分为四种手术方式:迷路后锁孔入路,经部分迷路及岩尖锁孔入路,经全迷路锁孔入路和经耳蜗锁孔入路。采用6具(12侧)经4%甲醛固定、颅内动静脉乳胶灌注、已建立导航资料的成人尸头行显微解剖,依次模拟上述锁孔入路。运用Stryker神经导航系统依次测定每种入路的岩斜区显露面积和手术操作自由度,统计学分析处理。
结果:1、四种锁孔入路的岩斜区显露面积依次为(93.1±17.6)mm2、(340.1±47.1)mm2、(357.4±56.4)mm2、(377.5±59.4)mm2;迷路后锁孔入路显著小于后三种术式(均P<0.01),后三者相互之间无显著差异(均P>0.05)。2、手术操作自由度依次为(555.1±164.1)mm2、(714.1±203.8)mm2、(847.2±186.7)mm2、(906.8±204.6)mm2;经部分迷路及岩尖、经全迷路、经耳蜗三种锁孔入路均明显高于迷路后锁孔入路(均P<0.01),经全迷路和经耳蜗两种锁孔入路均高于经部分迷路及岩尖锁孔入路(均P<0.01),但经全迷路和经耳蜗锁孔入路之间、经部分迷路及岩尖和经全迷路锁孔入路之间均无显著差异(均P>0.05)。
结论:四种手术方式的创伤依次增大。迷路后锁孔入路理论上不损伤听力和面神经功能,其对岩斜区的显露相对有限。经部分迷路及岩尖锁孔入路的显露范围更广,且面神经功能和听力得以保留的可能性较高。经全迷路锁孔入路对病变处理更为方便,但并不能进一步增加岩斜区的显露。经耳蜗锁孔入路也不能进一步增加岩斜区的显露,但适用于侵及岩段颈内动脉的病变的手术。
Part I: Design and Microsurgical Anatomy of the Presigmoid Retrolabyrinthine Keyhole Approach
Objective: To design a new presigmoid retrolabyrinthine keyhole approach based on minimally invasive keyhole idea and explore its feasibility and indications, which can be regarded as the bases of this approach in clinical use.
Methods: Eight adult cadaveric heads fixed by formalin and perfused intracranial vessels by red and blue latex were used in this study. Based on the study of the skin incision of conventional presigmoid transpetrosal approach, a 7-cm postauricular C-shaped skin incision of presigmoid keyhole approach was designed and performed 1 cm behind the helix, with its upper border just above the pinna and inferior margin at the level of the intertragic notch. After stripping partial mastoid and temporal craniotomy, a 3.5cm×3cm bone window was performed. On ligating and dividing the superior petrosal sinus, retracting the cerebellar hemisphere and temporal lobe, many anatomic structures could be observed under microscope.
Results: The important approach-relative structures could totally be exposed via the 7-cm postauricular C-shaped skin incision and the 3.5cm×3cm bone window. By means of adjusting head position and the angle of microscope, the ipsilateralⅢ,Ⅳ,Ⅴ,Ⅶ,Ⅷ,Ⅸ,Ⅹcranial nerves, posterior communicating artery, posterior cerebral artery, superior cerebellar artery, anterior inferior cerebellar artery, middle and superior segment of basilar artery, superior clivus, posterior cavernous sinus and the ventral lateral aspect of pons were exposed via this keyhole approach.
Conclusion: The novel presigmoid retrolabyrinthine keyhole approach has practical value for clinical applications. With the techniques of modern microsurgery, several diseases such as petroclival meningeoma, small to medium acoustic neuroma without internal acoustic meatus invasion, tumor located at the ventrally lateral aspect of pons, aneurysm arising at middle or superior segment of basilar artery could be operated on via this presigmoid retrolabyrinthine keyhole approach without drilling the labyrinthine.
Part II: Anatomical Study on the Presigmoid Translabyrinthine Keyhole Approach Assisted by Neuronavigation
Objective: To design new presigmoid translabyrinthine keyhole approach assisted by neuro-navigation system according to the keyhole idea,and to explore the possibility of removing the approach-correlated bone precisely.
Methods: Navigation data were established on 8 cadaveric heads fixed by formalin and perfused intracranial vessels with colored silicone. Before the operation, circumscriptions of sigmoid sinus, bony labyrinth and internal auditory canal were outlined with different colors in the navigation system in order to protect them in operation. A 7cm“C”shape skin incision was performed 1cm behind the helix with its super border near apex satyri and inferior margin at the level of intertragic notch. After elevating the skin flap and musculofascial flap respectively, a 3.5 cm×3 cm bone window was performed assisted by neuro-navigation. After skeletonized the sigmoid sinus, bony labyrinth and the canal for facial nerve, partial labyrinthectomy with petrous apicectomy and complete labyrinthectomy were performed by turns. The amount of dura exposed, the length of important structures exposed and the maximal angle of vision were measured in each step, and the anatomic structures were observed.
Results: The incision of the presigmoid retrolabyrinthine keyhole approach fully met the needs of the presigmoid translabyrinthine keyhole approach. The bone overlying sigmoid sinus and bony labyrinth, the partial labyrinth and petrous apex, the whole labyrinth could precisely be drilled with the aid of neuro-navigation, which could avoid the bewilder in drilling process. This approach provided wide exposure to petroclival region, cerebellopontine angle, prepontine region and posterior cavernous sinus; an area between the III~XI cranial nerves was easily visible without significant brain retraction. Camparing with the retrolabyrinthine keyhole approach, both partial labyrinthectomy with petrous apicectomy and complete labyrinthecotomy can significantly increased the horizontal and vertical exposure, the length of some important structures and the maximal angle of vision (P<0.01), but there were no significant differences between partial labyrinthectomy with petrous apicectomy and complete labyrinthecotomy (P>0.05).
Conclusion: The presigmoid translabyrinthine keyhole approach was feasible to be performed in our study. It provided easy and excellent exposure of the petroclival region and accorded to the keyhole idea. The approach correlated bone could be removed precisely assisted by neuronavigation system. The exposure was obviously increased by partial labyrinthectomy with petrous apicectomy or complete labyrinthecotomy, the former provided an excellent chance of hearing and facial nerve preservation..
Part III: Quantification of the Presigmoid Transpetrosal Keyhole Approach to the Petroclival Region Assisted by Neuronavigation
Objective: The goal of this study was to evaluate a new presigmoid transpetrosal keyhole approach based on quantitative measurements of the exposure of petroclival area assisted by Stryker neuronavigation system, which could be regarded as the bases of clinical application.
Methods: The presigmoid transpetrosal keyhole approach was divided into four increasingly morbidity-producing steps: retrolabyrinthine keyhole approach (RLK), partial labyrinthectomy with petrous apicectomy keyhole approach (PLPAK), translabyrinthine keyhole approach (TLK) and transcochlear keyhole approach (TCK). Six latex-injected cadaveric heads (twelve sides) underwent dissection in which Stryker neuronavigation system was used. The area of petroclival exposure and surgical freedom with each subsequent dissection were calculated.
Results: The exposed petroclival area of the four presigmoid transpetrosal keyhole approaches were(93.1±17.6)mm2(,340.1±47.1)mm2(,357.4±56.4)mm2 and(377.5±59.4)mm2, respectively. The exposed petroclival area of the PLPAK, TLK and TCK were all significantly increased than that of the RLK(P<0.01), but there were no significant differences between the PLPAK, TLK and TCK(P>0.05). The surgical freedom were (555.1±164.1)mm2,(714.1±203.8)mm2,(847.2±186.7)mm2 and(906.8±204.6)mm2, respectively. The surgical freedom of the PLPAK, TLK and TCK were all significantly increased than that of the RLK(P<0.01), and that of the TLK and TCK were all significantly increased than that of the PLPAK(P<0.01), but there were no significant differences between the TLK and TCK, the PLPAK and TLK(P>0.05).
Conclusions: With each step, the surgical injury increased. The retrolabyrinthine keyhole approach spares hearing and facial function but has relatively limited utility. For lesions without bone invasion, the PLPAK provides a much more versatile exposure with an excellent chance of hearing and facial nerve preservation. The TLK provides for greater versatility in treating lesions but clival exposure is not greatly enhanced. The TCK adds little in terms of intradural exposure but should be reserved for cases in which access to the petrous carotid artery is necessary.
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