神经导航辅助眉弓锁孔入路量化研究及临床意义

Quantization study of supraorbital keyhole approach assisted by neuro-navigation

目的：报道经眉弓锁孔入路对鞍区结构的显微外科解剖和显微技术。方法：在15例（30侧）经颈内动脉、椎动脉灌注红色乳胶的成人头标本上模拟经眉弓锁孔入路,借助手术显微镜（6~25倍）观察鞍区显微解剖结构,并在神经导航下量化Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ间隙面积,颈内动脉及分支、视神经长度。结果：眉弓锁孔入路对5间隙结构有很好暴露,通过第Ⅱ间隙打开Liliequist膜后可见基底动脉（BA）分叉,大脑后动脉（PCA）,小脑上动脉（SCA）及其穿通血管和动眼神经出脑干处及其行程,各间隙面积Ⅰ（85.64±6.87mm2）、Ⅱ（46.62±5.34mm2）、Ⅲ（18.97±2.78mm2）、Ⅳ（49.27±4.86mm2）、Ⅴ（35.95±3.41mm2）;颈内动脉眼段长（6.64±1.45mm）,交通段长（3.35±0.46mm）,脉络膜段长（3.75±0.67mm）,仔细分离切断周围的蛛网膜小梁,充分游离血管及其分支,在视交叉后上方可充分显露大脑前动脉（ACA）A1、A2段,前交通动脉复合体及Heubner返支,A1长（22.12±3.65mm）。左侧视神经为（15.15±2.54mm）,右（14.42±1.89mm）。结论：眉弓锁孔入路可对鞍区结构很好暴露,第Ⅰ间隙面积最大,Ⅰ、Ⅳ与入路方向一致,显露更为满意,通过Ⅱ间隙可观察Willis后环周围结构;处理鞍区肿瘤,以鞍区4个常规解剖间隙为主,联合第Ⅴ间隙可获得满意效果。

Objective：To study the microsurgery and microanatomy technique through supraorbital keyhole approach to saddle area. Methods： 15 silicone-injected adult cadaveric heads were dissected under operating microscope. The microstructures of sellar region were observed. The spaces of Ⅰ , Ⅱ, Ⅲ, Ⅳ, Ⅴ and the length of ICA and optic nerve were quantized by neuro-navigation. Results： Trans-supraorbital keyhole approach could expose five spaces very well. The bifurcation of BA, PCA, SCA and the full course of oculomotor nerve could be well observed by opening the Liliquist membrane through the space Ⅱ. The areas of Ⅰ , Ⅱ, Ⅲ, Ⅳ, Ⅴspaces were 85.64±6.87 mm^2, 46.62±5.34 mm^2, 18.97±2.78 mm^2, 49.27±4.86 mm^2 and 35.95±3.41 mm^2 respectively. The length of the optic, communicated and choroidal segments of ICA were 6.64± 1.45 mm, 3.35±0.46 mm and 3.75±.67 mm, respectively. The complex of anterior communicating artery and A1, A2 segments of ACA could be exposed above the optic chiasma by dissecting the arachnoid trabecula and blood vessels. Conclusions： Trans-supraorbital keyhole approach exposes microstructures of sellar region well. The spaceⅠ is the largest one. The posterior part of Willis ring can be observed through the space Ⅱ. Using Ⅰ, Ⅱ, Ⅲ and Ⅳ space could routinely deal with the tumors of sellar region. More satisfied exposure can be obtained using the space Ⅴ.