单鼻孔经蝶入路手术的切口选择及其解剖学依据

THE SELECTION AND ITS ANATOMIC BASIS OF THE INCISIONS FOR ENDONASAL TRANSSPHENOIDAL APPROACH

目的:通过对单鼻孔经蝶入路的解剖观测,探讨其手术切口的合理性。方法:在手术显微镜下,解剖15个防腐头颅标本,观察鼻中隔及其动脉血供;分析作者主刀的135例单鼻孔经蝶入路手术,关注切口的变迁、手术野的大小和鼻腔出血等问题,探讨其解剖学基础。结果:在手术径路上,鼻中隔骨与软骨结合部距前鼻孔大约3cm。鼻后中隔动脉的主干、上下分支起始部及上支越过骨与软骨结合部的平均外径分别为1.7mm、1.1mm、1.2 mm、0.7mm;上支沿蝶窦口的下外侧向内侧走行,与窦口平均相距8.2mm。术后2～7天出现鼻腔出血5例,均少于300ml,经填塞治愈;术后2～5周鼻腔出血5例,其中超过800ml 2例,均为鼻中隔后部切口,再次经鼻手术治愈;少于300ml3例,经填塞治愈。结论:经扩大蝶窦口入路及鼻中隔后部切口入路手术野小而倾斜,且容易损伤鼻后中隔动脉;鼻中隔中后部切口入路稍宽敞,但寻找粘骨膜间隙费时;鼻中隔中部切口入路最宽敞,解剖层面清晰,切口处血管细小,可能不太容易发生迟发性鼻腔大出血,可以推崇。

Objective： Through anatomic observation of endonasal transsphenoidal approach, the rationality of its surgical incisions was studied. Method： Under an operating microscope microdissection via endonasal transsphenoidal approach was undertaken on 15 formalin- fixed cadaver head specimens. The structure and arterial supply of nasal septum were observed. Clinical analysis was made on 135 operations performed by the first author via endonasal transsphenoidal approach. The issues including changes of incision, size of operative field and postoperative epistaxis were studied on the basis of the above anatomic observations. Results： The mean distance was 3cm from the conjunction point of septal bone portion and cartilage portion to anterior naris on the approach axis. Mean diameters of posterior septal artery, initial segment of its superior and inferior branch, and segment of superior branch through septal conjunction portion were 1.7mm, 1. 1mm, 1.2mm and 0.7mm, respectively. The superior branch originated inferior- laterally from sphenoid sinus aperture, ran medially to nasal septum, and mean distance between this branch and sphenoid sinus aperture was 8.2mm. Epistaxis with blood loss less than 300ml occurred in 5 cases from 5 to 7 days postoperatively, and healed by packing. Epistaxis occurred in 5 cases from 2 to 5 weeks postoperatively. Of them, Blood loss exceeding 800ml in 2 cases, and healed by reoperation. Blood loss less than 200ml appeared in 3 cases which healed by packing. Conclusion： Extended sphenoid sinus aperture approach and posterior septal approach provide a narrow and oblique operative field, which makes posterior septal artery easily injured. Operative field provided by postmedian septal approach is slightly wide, but inter - mucoperiosteal gap is hard to be found. Middle septal approach is deserved commendation because it provides a widest operative field, clear anatomical layers, much thin mucosal vessels in the incision area and lower possibility of delayed epistaxis.