鼻内镜蝶鞍、翼腭窝及相关区域手术解剖及外科技术研究
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摘要
鼻内镜技术在颅底部位的应用为颅底病变的治疗提供了一种新的有效的方法,近年来得到迅速的发展,缺乏方便实用的解剖学研究和适用于经鼻内镜颅底手术的器械是限制鼻内镜颅底外科进一步发展的主要原因,为提高该区域手术的操作水平,本课题主要从蝶鞍区、翼腭窝及相关区域的立体解剖和支撑鼻内镜技术的探索两方面展开研究。
第一部分鼻内镜蝶鞍、翼腭窝及相关区域手术解剖研究
1、设计了颅底解剖结构的立体测量方法。利用MicronTracker双目视觉导航仪研制了可以同时测量角度和距离的空间定位工具,经与传统的游标卡尺和角度转台进行对比,其测量结果的精确性没有差异;以额骨平面与正中矢状面为基准平面,鼻棘侧缘点及鼻底前缘中点为基准点,用解剖结构与基准点和基准平面之间的距离和角度作为其空间定位参数,方便实用,并且从数学原理上证明了这种方法的合理性;将基于MicronTracker双目视觉导航仪的立体测量方法在干尸头上进行试用,证实可实时读取探针的俯仰角、方向角及移动距离;额骨平面与正中矢状面与鼻腔及颅底结构空间关系恒定,可作为确定鼻腔、前颅底解剖标志空间定位的基准平面。
2、研究了蝶鞍区的解剖结构特点和三维关系。鼻底平面、矢状面、S点(鼻棘侧缘点)、M点(上颌线中点)可作为定位蝶鞍区重要解剖结构的基准平面和基准点;蝶窦口下缘、窦前嵴顶点、总腱环内壁前缘中点、颈内动脉-视神经隐窝、球形鞍底前缘中点、蝶窦后壁上缘中点、蝶窦后壁上缘外侧点、斜坡后缘中部顶点、斜坡后缘外侧顶点是经鼻内镜蝶鞍区手术的重要解剖结构或参照点;应用3D-max9.0和AutoCAD2008软件,建立经鼻蝶鞍区手术解剖结构的立体定位模型,用以显示所关注的解剖结构的三维立体关系,该模型可以任意旋转和移动,方便观察、演示和研究手术器械的运动轨迹;蝶窦的气化程度变异较大,是影响经鼻蝶鞍区手术的重要因素,了解蝶窦后壁底部三角的存在及参数,有助于经鼻斜坡区手术中开放斜坡骨质的定位和操作;蝶窦壁九分区法的立体模型丰富了鼻内镜下蝶窦壁九分区法的内容,使其更加方便于指导手术;了解颈内动脉床突段(C5)和海绵窦段(C4)后曲部的三维关系对于避免手术误伤有重要意义。
3、研究了翼腭窝及相关区域的解剖结构特点和三维关系。鼻底平面、矢状面、S点、AM点(上颌窦下壁前缘中点)可作为定位翼腭窝及相关区域重要解剖结构的基准平面和基准点;A点(上颌窦后内壁交界的凹陷)、蝶腭孔前壁上缘、颌内动脉第一分支动脉根部、腭大管上缘、翼管前口下缘中点、圆孔外口下缘中点、翼突根部前缘外侧点、卵圆孔前缘、破裂孔内缘、颈内动脉前曲部前缘、颈内动脉后曲部前缘是经鼻内镜翼腭窝及相关区域手术中重要的解剖结构或参照点;应用3D-max9.0和AutoCAD2008软件,建立翼腭窝及相关区域解剖结构的立体定位模型,用以显示所关注的解剖结构的三维立体关系;颌内动脉的分支及走行遵循一定的规律;内镜下经鼻/上颌窦-翼腭窝-海绵窦入路有良好的应用前景,值得深入探讨。
第二部分支撑鼻内镜外科技术研究
1、自行设计了支撑鼻内镜手术辅助系统,包括鼻内镜支撑架、电控变速冲洗吸引系统、鼻咽封闭气囊和线式双极电凝器四部分,用以解决目前鼻内镜手术中存在的单手操作、血污镜头和深部术区电凝止血的问题,并且制作成功。
2、用鼻内镜支撑架、电控变速冲沈吸引系统、线式双极电凝器在杂犬鼻腔内进行了支撑鼻内镜模拟手术试验,在动物试验验证过程中实现的手术操作模式合理高效,即一手负责手术执行操作与移动镜体,另一手负责冲洗吸引以保持术野清晰;初步证明该系统实现了方便的双手操作、实时清洗镜头和深部术区止血的手术操作,有助于提高操作的准确性和整个手术的效率,可以作为鼻内镜手术有效的辅助器械。
Transnasal endoscopic surgery is a new technique for the diseases of skull base and has developed rapidly in the past decades.However,the development of the technique is limited by lacking convenient,practical anatomical study and suitable surgical instruments.The three-dimensional anatomy of the sellar region,the pterygopalatine fossa and related structures were studied,and a noval surgical technique-the assistant technique of the transnasal endoscopic surgery named by our reaseach team was explored.
The first part:Transnasal endoscopic surgery of the sellar region,the pterygopalatine fossa and related structures:anatomical study
1.Designing a new tool,which can measure angle and distance simultaneously based on the MicronTracker binocular visual navigation system.
The tool's accuracy had no statistical difference as compared with vernier caliper and turntable.The frontal bone plane and sagittal plane are used as datum plane,the lateral margin point of nasal spine and middle point of anterior border of basis nasi are used as datum point,then the distance and angle are used as the anatomical structure's localization parameter,the method was proved logically by math principle. In order to test the new tool,we measure some angles and distances on dry adult cranium specimens with it.We can get the pitching angle,direction angle and distance from the tool conveniently.The relationship between the landmarks of the skull base, the nasal cavity and the frontal bone plane,the sagittal plane is stable,then the planes may be used as the datum plane to look for the landmarks in the anatomic study,even in transnasal endoscopic skull base surgery in the future.
2.Studying the anatomical characteristics and three-dimensional relation of the sellar region.
The basis nasi plane and median sagittal plane are used as datum plane,S point (the lateral margin point of nasal spine) and M point(maxillary line midpoint) are used as datum point to orientate the structures,inferior limbus of aperture of sphenoidal sinus,vertex of sphenoidal sinus anterior ridge,medial point of the common tendinous ring medial wall,Optic—carotid recess,medial point of sellar turcica anterior limbus,medial point of sphenoidal sinus posterior wall superior limbus,lateral point of sphenoidal sinus posterior wall superior limbus,medial vertex of clivus posterior limbus,lateral vertex of clivus posterior limbus are useful landmarks or anchor point.We used 3D-max9.0 and AutoCAD2008 to set up three-dimensional anatomical model of the anatomical structures,which can rotate and move randomly,be easy to observe,display and study the moving trajectory of surgical instruments.We found that,gasification degree of sphenoidal sinus is varied, which is an important factor on transnasal endoscopic surgery;being familiar with the basic triangle of posterior wall of sphenoidal sinus is helpful in the transnasal sphenoidal surgery.The three-dimensional anatomical model of sphenoidal sinus enriched the content of the"#"shape subdivision and made it guide surgery more conveniently.Knowing the three-dimensional anatomical relationship of C5 and C4 of internal carotid artery is helpful to reduce complications.
3.Studying the anatomical characteristics and three-dimensional relation of the pterygopalatine fossa and related structures.
The basis nasi plane and median sagittal plane are used as datum plane,S point and AM point(anteroinferior wall midpoint of maxillary sinus) are used as datum point to orientate the structures,the A point(a concave of the maxillary sinus posterior-medial wall),superior limbus of sphenopalatine foramen anterior wall,the first branch root of internal maxillary artery,superior border of greater palatine canal, middle point of the vadian canal anterior limbus,middle point of the foramen rotundum,lateral point of the pterygoid root anterior limbus,anterior limbus of foramen ovale,anterior limbus of foramen lacerum,anterior limbus of the internal carotid artery posterior bend,anterior limbus of the internal carotid artery anterior bend are useful landmarks or anchor points.We used 3D-max9.0 and AutoCAD2008 to set up three-dimensional anatomical model of the anatomical structures,which can display the 3D—relationships about the structures.We find a rule of the branches and course of maxillary artery.It has a good application prospect for endoscopic transnasal/maxillary-peterygopalatine fossa approach to cavernous sinus,which deserves further study.
The second part:The assistant technique of the transnasal endoscopic surgery stt
1.Designing an assistant system of the transnasal endoscopic surgery.
The symtem are including endoscope holder,electricity-controlled irrigation and suction system,nasopharynx blocking aerocyst and soft linear bipolar coagulator. With the system,we can solve the problems such as singlehanded operation,lens stained by blood and electric coagulation in the deep operation region in the transnasal endoscopic surgery.We manufactured all the instruments successfully.
2.Performing a mimic transnasal endoscopic surgery in the nasal cavity of a mongrel dog using the instruments.
We have set up a reasonable and efficient operation mode with the instruments, namely one hand operates and moves the endoscope,the other hand keeps the operation field and the endoscope clear with the electricity-controlled irrigation and suction system.The mimic surgery proved the system could help us to operate conveniently by two hands and keep the endoscope clear,to improve the accuracy and efficiency in transnasal endoscopic surgery.
第一部分鼻内镜蝶鞍、翼腭窝及相关区域手术解剖研究
1、设计了颅底解剖结构的立体测量方法。利用MicronTracker双目视觉导航仪研制了可以同时测量角度和距离的空间定位工具,经与传统的游标卡尺和角度转台进行对比,其测量结果的精确性没有差异;以额骨平面与正中矢状面为基准平面,鼻棘侧缘点及鼻底前缘中点为基准点,用解剖结构与基准点和基准平面之间的距离和角度作为其空间定位参数,方便实用,并且从数学原理上证明了这种方法的合理性;将基于MicronTracker双目视觉导航仪的立体测量方法在干尸头上进行试用,证实可实时读取探针的俯仰角、方向角及移动距离;额骨平面与正中矢状面与鼻腔及颅底结构空间关系恒定,可作为确定鼻腔、前颅底解剖标志空间定位的基准平面。
2、研究了蝶鞍区的解剖结构特点和三维关系。鼻底平面、矢状面、S点(鼻棘侧缘点)、M点(上颌线中点)可作为定位蝶鞍区重要解剖结构的基准平面和基准点;蝶窦口下缘、窦前嵴顶点、总腱环内壁前缘中点、颈内动脉-视神经隐窝、球形鞍底前缘中点、蝶窦后壁上缘中点、蝶窦后壁上缘外侧点、斜坡后缘中部顶点、斜坡后缘外侧顶点是经鼻内镜蝶鞍区手术的重要解剖结构或参照点;应用3D-max9.0和AutoCAD2008软件,建立经鼻蝶鞍区手术解剖结构的立体定位模型,用以显示所关注的解剖结构的三维立体关系,该模型可以任意旋转和移动,方便观察、演示和研究手术器械的运动轨迹;蝶窦的气化程度变异较大,是影响经鼻蝶鞍区手术的重要因素,了解蝶窦后壁底部三角的存在及参数,有助于经鼻斜坡区手术中开放斜坡骨质的定位和操作;蝶窦壁九分区法的立体模型丰富了鼻内镜下蝶窦壁九分区法的内容,使其更加方便于指导手术;了解颈内动脉床突段(C5)和海绵窦段(C4)后曲部的三维关系对于避免手术误伤有重要意义。
3、研究了翼腭窝及相关区域的解剖结构特点和三维关系。鼻底平面、矢状面、S点、AM点(上颌窦下壁前缘中点)可作为定位翼腭窝及相关区域重要解剖结构的基准平面和基准点;A点(上颌窦后内壁交界的凹陷)、蝶腭孔前壁上缘、颌内动脉第一分支动脉根部、腭大管上缘、翼管前口下缘中点、圆孔外口下缘中点、翼突根部前缘外侧点、卵圆孔前缘、破裂孔内缘、颈内动脉前曲部前缘、颈内动脉后曲部前缘是经鼻内镜翼腭窝及相关区域手术中重要的解剖结构或参照点;应用3D-max9.0和AutoCAD2008软件,建立翼腭窝及相关区域解剖结构的立体定位模型,用以显示所关注的解剖结构的三维立体关系;颌内动脉的分支及走行遵循一定的规律;内镜下经鼻/上颌窦-翼腭窝-海绵窦入路有良好的应用前景,值得深入探讨。
第二部分支撑鼻内镜外科技术研究
1、自行设计了支撑鼻内镜手术辅助系统,包括鼻内镜支撑架、电控变速冲洗吸引系统、鼻咽封闭气囊和线式双极电凝器四部分,用以解决目前鼻内镜手术中存在的单手操作、血污镜头和深部术区电凝止血的问题,并且制作成功。
2、用鼻内镜支撑架、电控变速冲沈吸引系统、线式双极电凝器在杂犬鼻腔内进行了支撑鼻内镜模拟手术试验,在动物试验验证过程中实现的手术操作模式合理高效,即一手负责手术执行操作与移动镜体,另一手负责冲洗吸引以保持术野清晰;初步证明该系统实现了方便的双手操作、实时清洗镜头和深部术区止血的手术操作,有助于提高操作的准确性和整个手术的效率,可以作为鼻内镜手术有效的辅助器械。
Transnasal endoscopic surgery is a new technique for the diseases of skull base and has developed rapidly in the past decades.However,the development of the technique is limited by lacking convenient,practical anatomical study and suitable surgical instruments.The three-dimensional anatomy of the sellar region,the pterygopalatine fossa and related structures were studied,and a noval surgical technique-the assistant technique of the transnasal endoscopic surgery named by our reaseach team was explored.
The first part:Transnasal endoscopic surgery of the sellar region,the pterygopalatine fossa and related structures:anatomical study
1.Designing a new tool,which can measure angle and distance simultaneously based on the MicronTracker binocular visual navigation system.
The tool's accuracy had no statistical difference as compared with vernier caliper and turntable.The frontal bone plane and sagittal plane are used as datum plane,the lateral margin point of nasal spine and middle point of anterior border of basis nasi are used as datum point,then the distance and angle are used as the anatomical structure's localization parameter,the method was proved logically by math principle. In order to test the new tool,we measure some angles and distances on dry adult cranium specimens with it.We can get the pitching angle,direction angle and distance from the tool conveniently.The relationship between the landmarks of the skull base, the nasal cavity and the frontal bone plane,the sagittal plane is stable,then the planes may be used as the datum plane to look for the landmarks in the anatomic study,even in transnasal endoscopic skull base surgery in the future.
2.Studying the anatomical characteristics and three-dimensional relation of the sellar region.
The basis nasi plane and median sagittal plane are used as datum plane,S point (the lateral margin point of nasal spine) and M point(maxillary line midpoint) are used as datum point to orientate the structures,inferior limbus of aperture of sphenoidal sinus,vertex of sphenoidal sinus anterior ridge,medial point of the common tendinous ring medial wall,Optic—carotid recess,medial point of sellar turcica anterior limbus,medial point of sphenoidal sinus posterior wall superior limbus,lateral point of sphenoidal sinus posterior wall superior limbus,medial vertex of clivus posterior limbus,lateral vertex of clivus posterior limbus are useful landmarks or anchor point.We used 3D-max9.0 and AutoCAD2008 to set up three-dimensional anatomical model of the anatomical structures,which can rotate and move randomly,be easy to observe,display and study the moving trajectory of surgical instruments.We found that,gasification degree of sphenoidal sinus is varied, which is an important factor on transnasal endoscopic surgery;being familiar with the basic triangle of posterior wall of sphenoidal sinus is helpful in the transnasal sphenoidal surgery.The three-dimensional anatomical model of sphenoidal sinus enriched the content of the"#"shape subdivision and made it guide surgery more conveniently.Knowing the three-dimensional anatomical relationship of C5 and C4 of internal carotid artery is helpful to reduce complications.
3.Studying the anatomical characteristics and three-dimensional relation of the pterygopalatine fossa and related structures.
The basis nasi plane and median sagittal plane are used as datum plane,S point and AM point(anteroinferior wall midpoint of maxillary sinus) are used as datum point to orientate the structures,the A point(a concave of the maxillary sinus posterior-medial wall),superior limbus of sphenopalatine foramen anterior wall,the first branch root of internal maxillary artery,superior border of greater palatine canal, middle point of the vadian canal anterior limbus,middle point of the foramen rotundum,lateral point of the pterygoid root anterior limbus,anterior limbus of foramen ovale,anterior limbus of foramen lacerum,anterior limbus of the internal carotid artery posterior bend,anterior limbus of the internal carotid artery anterior bend are useful landmarks or anchor points.We used 3D-max9.0 and AutoCAD2008 to set up three-dimensional anatomical model of the anatomical structures,which can display the 3D—relationships about the structures.We find a rule of the branches and course of maxillary artery.It has a good application prospect for endoscopic transnasal/maxillary-peterygopalatine fossa approach to cavernous sinus,which deserves further study.
The second part:The assistant technique of the transnasal endoscopic surgery stt
1.Designing an assistant system of the transnasal endoscopic surgery.
The symtem are including endoscope holder,electricity-controlled irrigation and suction system,nasopharynx blocking aerocyst and soft linear bipolar coagulator. With the system,we can solve the problems such as singlehanded operation,lens stained by blood and electric coagulation in the deep operation region in the transnasal endoscopic surgery.We manufactured all the instruments successfully.
2.Performing a mimic transnasal endoscopic surgery in the nasal cavity of a mongrel dog using the instruments.
We have set up a reasonable and efficient operation mode with the instruments, namely one hand operates and moves the endoscope,the other hand keeps the operation field and the endoscope clear with the electricity-controlled irrigation and suction system.The mimic surgery proved the system could help us to operate conveniently by two hands and keep the endoscope clear,to improve the accuracy and efficiency in transnasal endoscopic surgery.
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