神经内窥镜下经鼻—蝶窦鞍区肿瘤切除术的解剖学研究
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摘要
本论文的研究目的:是通过对鞍区断层解剖和神经内窥镜下经鼻-蝶窦外科入路解剖的比较研究,了解鞍区区域内重要的解剖定位标志和特点,临床上神经内窥镜下经鼻-蝶窦鞍区肿瘤切除术会有损伤颈内动脉和海绵窦引起致命性出血以及损伤视神经或视交叉导致失明等严重并发症发生的可能,为避免这些并发症的发生,除了提高设备水平外,熟练掌握神经内窥镜下经鼻-蝶窦入路解剖具有非常重要的意义。虽然神经内窥镜下经鼻-蝶窦鞍区肿瘤切除术表现出优异的特性,但也存在着一些缺点,它所提供的是二维图像,缺乏立体感。鞍区局部组织断层解剖则提供了该部位的连续切片资料,帮助手术者建立鞍区立体解剖观念,了解鞍区重要结构的三维解剖关系,对临床经鼻-蝶窦入路鞍区肿瘤切除术具有指导作用。为提高经鼻-蝶窦入路切除鞍区肿瘤的手术成功率和安全性提供解剖学依据。方法:第一部分:取用经福尔马林固定后的成人12例尸头鞍区部为实验材料,步骤:①标本脱钙:所用材料用10%盐酸浸泡12～20d,直至骨组织可用针刺入时为止;②冲洗:取出标本,用循环水冲洗24h;③常规脱水:将标本逐级脱水,直到标本变硬为止;④浸胶:将脱水后的标本块先浸入5%火棉胶中,在真空干燥箱内以66kPa的压力抽真空30min,静置1天后,再抽真空,再静置1天后浸入8%火棉胶中;以同样条件抽真空2次。⑤包埋与制块:用15%火棉胶作为包埋剂,包埋块的形成约15～30d。将包埋块置入70%酒精中硬化保存;⑥焊块与切片:采用德国酒浸L型切片机制备切片,对标本进行连续切片,切片厚度设置在0.5～1.0mm。第二部分:采用成人尸体头颅标本6例,均经10%福尔马林溶液固定。神经内窥镜下模拟经鼻-蝶窦手术入路,使用KARL STORZ神经内窥镜系统观察鼻腔、蝶窦、颅内鞍区解剖学形态。记录并了解手术区域中特别是蝶鞍及周围结构的解剖形态,发现一些与手术相关的重要标志性结构,并予以测量和分析。结果:①海绵窦是一个充满血液的静脉通道,分为前下、后上、内侧和外侧4个主要间隙。其中海绵窦后上间隙最大,海绵窦外侧间隙最小。同时,在海绵窦内仍可见少量静脉存在。②海绵窦外侧壁可分为浅、深两层。浅层即硬脑膜层,较为致密。深层为疏松结缔组织,有动眼神经、滑车神经、眼神经和上颌神经穿行其中。此外,有77.28%的标本在海绵窦外侧壁两层之间存在静脉窦;③海绵窦面积等指标在冠状切片由前向后逐渐增大,以垂体前叶中部或垂体柄层面为最大,而后逐渐减小;④蝶窦口是最重要的定位标志,蝶窦开口位于上鼻甲后上方的蝶筛隐窝,蝶筛隐窝虽然是恒定存在的结构,但形态变异很大,因而不能作为非常可靠的定位解剖标志;⑤蝶窦中隔多数不在中线而偏于一侧,且多偏于左侧,故蝶窦中隔不能作为经鼻-蝶窦入路鞍区肿瘤切除术定中线的标志;⑥初步证实蝶鞍一侧或两侧的缺失区或薄弱区可以作为鞍区肿瘤从鞍区至鞍旁区发展的通道,海绵窦内侧壁薄弱甚至缺如是垂体腺瘤侵犯海绵窦的解剖学基础。结论:鞍区局部组织火棉胶包埋法的连续断层切片提供了该部位的连续切片解剖资料,对临床经鼻-蝶窦入路鞍区肿瘤切除术具有指导作用。经鼻-蝶窦入路时神经内窥镜可以提供一个全景的术野,可较好地显露蝶窦、鞍区颅底区域。内窥镜下经鼻-蝶窦入路从解剖学角度可以处理大部分以往必须经颅手术的鞍区病变。此入路的优点是不开颅,避免了牵拉脑组织和对神经、血管等结构的手术副损伤。对于手术中保护重要神经、血管结构意义重大。
Objective The objective of the study is to explore the important anatomical mark point and its characteristics in sella region,through the comparative analysis of sella region cross-sectional anatomy and neuroendoscopic endonasal trans-sphenoidal surgical anatomy.In clinical practice,neuroendoscopic endonasal trans-sphenoidal removal of the tumor in sella region can possibly result in the serious complications of 'fatal bleeding caused by injury of the internal carotid artery and cavernous sinus' and 'blindness caused by injury of optic nerve or optic chiasm'.In order to avoid these complications,in addition to improve the equipments,proficiency in neuroendoscopic endonasal trans-sphenoidal surgical anatomy is of great importance.Although neuroendoscopic endonasal trans-sphenoidal removal of the tumor in sella region shows its perfect features,it also has some weaknesses.It provides two-dimensional images which lack three-dimensional effects. However,cross-sectional anatomy in sella region can provide continuous anatomic slices of the specific site,and help the operator to develop the idea of three-dimensional anatomy of sella region. Understanding the three-dimensional anatomic relationship of important structures in sella region can play a guiding role for endonasal trans-sphenoidal removal of the tumor in sella region in practice,and provide anatomic basis for improving its success rate and safety.
Methods
The first part:
Heads from 12 adult cadavers embalmed by formalin solution were used as materials.Procedures included:①specimen decalcification:the materials were immersed in 10%hydrochloric acid for 7～15 days,until the bone tissue can be pierced by needle;②flushing:the specimen was taken out and flushed by circulating water for 24 hours;③routine method of dehydration:the specimen was dehydrated step by step,until it became hard;④immersion in celloidin:dehydrated specimen was immersed in 5%celloidin, vacuumized for 30 minutes using 66 kPa in vacuum drying oven, vaccumized again after one-day standing.And once again after one-day standing,the specimen was immersed in 8%celloidin,and vaccumized twice under the same condition.⑤making embedding block:15%celloidin was used as embedding medium,it took about 15-30 days to make embedding block,and then the embedding block was hardened and stored in 70%alcohol;⑥making slice:the researcher used L-type cerebral microtome made in German to make continuous slices of the specimen,whose thickness was set at 0.5～1.0mm.
The second part:
Heads from 6 adult cadavers embalmed by 10%formalin solution were used.The researcher imitated endonasal trans-sphenoidal surgical approach,and used KARL STORZ neuroendoscopy system to observe and document the anatomic structure of nasal cavity,sphenoid sinus,and intracranial sella region.The researcher also observed anatomic structure of surgical region,in particular,the sella region and its surrounding structures, identified some important surgery-related marking points,and measured and analyzed
Results Cavernous sinus is a venous channel filled with blood, and divided into 4 major spaces,i.e.inferior-anterior, superior-posterior,medial and lateral,among which superior-posterior part is the largest,while lateral part is the smallest.And there are still a few veins in cavernous sinus.The lateral wall of cavernous sinus can be divided into superficial and deeper parts.The superficial layer is compact endocranium.The deeper part is loose connective tissue,where oculomotorius, pathetic nerve,nervi ophthalmicus,and superior maxillary nerve go through.In addition,77.28%of the specimens have sinuses venosus between two layers of lateral wall of cavernous sinus;The area of cavernous sinus and other indicators in coronal slices gradually become larger from anterior to posterior part,among which the area of middle part of pituitarium anterius or pituitary stalk is the largest, and then gradually became smaller;The aperture of sphenoidal sinus is the most important mark point,which is located at spheno-ethmoic recess at the superior posterior part of superior nosepiece.Although spheno-ethmoic recess is always an existing structure,its conformation varies greatly,so it can not be used as a very reliable anatomic mark point;In most cases,the middle septum of sphenoid sinus is not in the median line,but deflected to one side, and mostly to the left side,as a result,it can not be regarded as the mark point of the median line in endonasal trans-sphenoidal removal of the tumor in sella region;The study preliminarily demonstrated that the vacancy or weakness of one side or two sides of the sella turcica may be used as the channel,through which the tumors in sella region develop from it toward areas around it.The weakness or even vacancy of medial wall of cavernous sinus is the anatomic basis for the encroachment on cavernous sinus by pituitary adenoma.
Conclusions Continuous anatomic slices in the local tissue of sella region made by using the technique of celloidin embedding provided anatomic information about the continuous slices of the specific area,and played a directing role for endonasal trans-sphenoidal removal of the tumor in sella region in clinical practice.When using endonasal trans-sphenoidal approach,the neuroendoscopy can provide a panoramic operating field and better exposure of sphenoid sinus and basis cranii in sella region.From anatomic perspective,the neuroendoscopic endonasal trans-sphenoidal approach can treat most of the pathological changes in sella region which previously must be treated through transcranial operation.The advantages of this operation approach include the following:not using craniotomy,avoiding traction of brain tissue and accompanied damage of nerves and blood vessels and other structures,and being of great significance for protecting important nerves and blood vessels during operation.
Objective The objective of the study is to explore the important anatomical mark point and its characteristics in sella region,through the comparative analysis of sella region cross-sectional anatomy and neuroendoscopic endonasal trans-sphenoidal surgical anatomy.In clinical practice,neuroendoscopic endonasal trans-sphenoidal removal of the tumor in sella region can possibly result in the serious complications of 'fatal bleeding caused by injury of the internal carotid artery and cavernous sinus' and 'blindness caused by injury of optic nerve or optic chiasm'.In order to avoid these complications,in addition to improve the equipments,proficiency in neuroendoscopic endonasal trans-sphenoidal surgical anatomy is of great importance.Although neuroendoscopic endonasal trans-sphenoidal removal of the tumor in sella region shows its perfect features,it also has some weaknesses.It provides two-dimensional images which lack three-dimensional effects. However,cross-sectional anatomy in sella region can provide continuous anatomic slices of the specific site,and help the operator to develop the idea of three-dimensional anatomy of sella region. Understanding the three-dimensional anatomic relationship of important structures in sella region can play a guiding role for endonasal trans-sphenoidal removal of the tumor in sella region in practice,and provide anatomic basis for improving its success rate and safety.
Methods
The first part:
Heads from 12 adult cadavers embalmed by formalin solution were used as materials.Procedures included:①specimen decalcification:the materials were immersed in 10%hydrochloric acid for 7～15 days,until the bone tissue can be pierced by needle;②flushing:the specimen was taken out and flushed by circulating water for 24 hours;③routine method of dehydration:the specimen was dehydrated step by step,until it became hard;④immersion in celloidin:dehydrated specimen was immersed in 5%celloidin, vacuumized for 30 minutes using 66 kPa in vacuum drying oven, vaccumized again after one-day standing.And once again after one-day standing,the specimen was immersed in 8%celloidin,and vaccumized twice under the same condition.⑤making embedding block:15%celloidin was used as embedding medium,it took about 15-30 days to make embedding block,and then the embedding block was hardened and stored in 70%alcohol;⑥making slice:the researcher used L-type cerebral microtome made in German to make continuous slices of the specimen,whose thickness was set at 0.5～1.0mm.
The second part:
Heads from 6 adult cadavers embalmed by 10%formalin solution were used.The researcher imitated endonasal trans-sphenoidal surgical approach,and used KARL STORZ neuroendoscopy system to observe and document the anatomic structure of nasal cavity,sphenoid sinus,and intracranial sella region.The researcher also observed anatomic structure of surgical region,in particular,the sella region and its surrounding structures, identified some important surgery-related marking points,and measured and analyzed
Results Cavernous sinus is a venous channel filled with blood, and divided into 4 major spaces,i.e.inferior-anterior, superior-posterior,medial and lateral,among which superior-posterior part is the largest,while lateral part is the smallest.And there are still a few veins in cavernous sinus.The lateral wall of cavernous sinus can be divided into superficial and deeper parts.The superficial layer is compact endocranium.The deeper part is loose connective tissue,where oculomotorius, pathetic nerve,nervi ophthalmicus,and superior maxillary nerve go through.In addition,77.28%of the specimens have sinuses venosus between two layers of lateral wall of cavernous sinus;The area of cavernous sinus and other indicators in coronal slices gradually become larger from anterior to posterior part,among which the area of middle part of pituitarium anterius or pituitary stalk is the largest, and then gradually became smaller;The aperture of sphenoidal sinus is the most important mark point,which is located at spheno-ethmoic recess at the superior posterior part of superior nosepiece.Although spheno-ethmoic recess is always an existing structure,its conformation varies greatly,so it can not be used as a very reliable anatomic mark point;In most cases,the middle septum of sphenoid sinus is not in the median line,but deflected to one side, and mostly to the left side,as a result,it can not be regarded as the mark point of the median line in endonasal trans-sphenoidal removal of the tumor in sella region;The study preliminarily demonstrated that the vacancy or weakness of one side or two sides of the sella turcica may be used as the channel,through which the tumors in sella region develop from it toward areas around it.The weakness or even vacancy of medial wall of cavernous sinus is the anatomic basis for the encroachment on cavernous sinus by pituitary adenoma.
Conclusions Continuous anatomic slices in the local tissue of sella region made by using the technique of celloidin embedding provided anatomic information about the continuous slices of the specific area,and played a directing role for endonasal trans-sphenoidal removal of the tumor in sella region in clinical practice.When using endonasal trans-sphenoidal approach,the neuroendoscopy can provide a panoramic operating field and better exposure of sphenoid sinus and basis cranii in sella region.From anatomic perspective,the neuroendoscopic endonasal trans-sphenoidal approach can treat most of the pathological changes in sella region which previously must be treated through transcranial operation.The advantages of this operation approach include the following:not using craniotomy,avoiding traction of brain tissue and accompanied damage of nerves and blood vessels and other structures,and being of great significance for protecting important nerves and blood vessels during operation.
引文
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[4]Sekhar LN,Oliverira ED.Cranial microsurgery:approaches and techniques.1~(st)ed.Stuttgart:Thieme,1999:1-11.
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[1]Shimon I,Melmed S.Management of pituitary tumors.Ann Intern Med,1998,129(6):472-483.
[2]Kovacs K,Scheithauer B,Horvath E,et al.The World Health organization classification of adenohypophysial neoplasms.Cancer,1996,78:502-510.
[3]Black PM,Loeffler JS.Cancer of the nervous system.1~(st)ed.Massachusetts:Blackwell Science,1997:363-402.
[4]Sekhar LN,Oliverira ED.Cranial microsurgery:approaches and techniques.1~(st)ed.Stuttgart:Thieme,1999:1-11.
[5]Kaye AH,Black PM.Operative neurosurgery.1~(st)ed.London:Churchill Livingstone,2000:715-722.
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[10]Perneczky A,Fries G.Endoscope - assisted brain surgery:part 1evolution,basic concept,and current technique[J].Neurosurgery,1998,42:219-224.
[11]Czirjak S,Szeifert GT.Surgical experience with frontolateral craniotomy through a superciliary skin incision[J].Neurosurgery,2001,48:145-150.
[12]Elwany S,Yacout YM,Talat M,et al.Surgical anatomy of the sphenoid sinus[J].J Laryngol Otol,1983,97:227-241.
[13]杨松青,王根本.国人成人颅骨蝶窦的观察和测量[J].临床耳鼻咽喉科杂志,1989,3(1):198-201.
[14]Sethi DS,Stanley R,Pillay PK.Endoscopic anatomy of the sphenoid sinus and sella turcica[J].J Laryngol Otol,1995,109:951-955.
[15]Hamberger CA,HammerG,Norlen G,et al.Transantrosphenoidal hypophysectomy.Arch Otolargngol,1961,74:2-8.
[16]Elwany S,Yacout YM,Talat M,et al.Surgical anatomy of the sphenoid sinus.J Laryngol Otol,1983,97:227-241
[17]Renn WH,Rhoton AL.Microsurgical anatomy of the sellar region.J Neurosurg,1975,43:288-298.
[18]Bu GX.Variation of sphenoid sinus in relation to sella turcica.Chin Med J Engl,1990,103(4):324-325.
[19]Kinnman J.Surgical aspects of the anatomy of the sphenoidal sinus and the sella turcica[J]Anat,1997,124:541-553.
[20]陆书昌,范静平,廖建春,等.蝶窦气化类型解剖学研究.耳鼻咽喉一头颈外科,1996,3(4):324-325.
[21]Johnson DM,Hopkins RJ,Hanafee VIN,et al.The unprotected parasphenoidal carotid artery studied by high-resolution computed topography[J].Radiology,1985,155:137-141.
[22]Summers GW Nasal obstruction caused by a pituitary chromophobe adenoma.Laryngoscope,1976,86(1):17.
[23]Rhoton AL Jr.The sellar region[J].Neurosurgery,2002;51(4Suppl):335-374.
[2 4]孙敬武,汪银凤,陈晓虹,等.经鼻腔内窥镜蝶窦鞍区手术解剖极其临床应用[J].中国临床解剖学,2000:18(3):199-200.
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[31]Butler H.The development of certain human dural venous sinuses J.J Anat,1957,91:510
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[19]Kinnman J.Surgical aspects of the anatomy of the sphenoidal sinus and the sella turcica[J]Anat,1997,124:541-553.
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[38] Blevins LJ,Verity DK,Allen G,et al. aggressive pituitary tumors. J Oncology(Hunting), 1998,12(9): 1307.
[39] Cottier JP, Destrieux C, Brunereau L, et al. Cavernous sinus invasion by pituitary adenoma:MR imaging.Radiology, 2000,215(2):463-469.
[40] Kawamoto H, Uozumi T,Kawamoto K,et al. Type N collagenase activity andcavernous sinus invasion in human pituitary adenomas.J Acta Neurochir (Wien),1996,138(4):390.
[41] Selman WR, Laws ER Jr,Schetthauer BW,et al. The occurrence of dural invasion in pituitary adenomas. J Neurosurg, 1986,64:402-407.
[42] Kitz K,Knosp E,Koos WT,et al.Proliferation in pituitary adenomas:measurement by Mab K167. Acta Neurochir(wien). 1991,53,supple: 60-64.
[43] Taptas JN. The so-called cavernous sinus: A review of the controversy and its implications for neurosurgeons. Neurosurgery, 1982,11:712-717.
[44] Kawase T,Van Loveren H,Keller JT,et al. Meningeal architecture of the cavernous sinus: clinical and surgical implication. Neurosurg, 1996,39:527.
[45] Dolenc VV Relation of the cavernous sinus to the sella, in Anatomy and surgery of the cavernous sinus. Wien, Springer-Verlag, 1989,pp:118-130.
[46]郑覆平.经蝶手术的并发症及其防治.中国神经疾病杂志,1990,16(6):321.