扩大经蝶窦入路内镜下的解剖特点

Endoscopic anatomy involving the extended transsphenoidal approach

目的为扩大经蝶窦入路提供内镜解剖学资料。方法选择经10％甲醛固定、红色乳胶灌注双侧颈内及椎动脉的中国人成人带颈头颅标本20例行内镜入路相关数据测量；另选5例头颅标本，运用内镜模拟扩大经蝶窦入路对其相关结构进行解剖、观察、测量、照相。结果扩大经蝶窦人路可清晰显示鞍上、海绵窦、斜坡等区域的解剖结构。（1）内镜下鼻腔的标志有上中下鼻甲、蝶腭动脉等。蝶窦内有鞍底、斜坡凹陷及视神经、颈内动脉隆突等解剖标志。（2）内镜下蝶骨平板、鞍结节、鞍底、斜坡为中线区，内1／3视神经管及颈内动脉隆突为中线旁区，视神经－颈内动脉隐窝及上颌神经、下颌神经隆突为外侧区。（3）内镜下颈内动脉分为鞍旁段及斜坡旁段，前者细分为隐匿段、下水平段、前垂直段及上水平段，下水平段较实际长度明显变短。结论内镜下扩大经蝶窦入路可以清晰暴露邻近蝶窦的颅内及海绵窦内结构，提供从前方角度处理该区域病变的新途径。

Objective To provide pertinent anatomic data and details for the clinical application of the extended transsphenoidal approach; to probe the anatomic characteristic and method under endoscope; Methods 25 adult cadaver heads fixed in formalin were used to dessect, observe, measure and photograph the relationship between the neural and vascular structure and the important anatomic landmarks related to the extended transsphenoidal approach under endoscope. Results The posterior and lateral wall of sphenoidal sinus could be well exposed by bilateral approach under endoscope. The clinical application of endoscope could improve the illumination of the operative field, magnify the objects and provide twodimensional images. The distortion of the images under endoscope depended upon the distance between the lens and the object as well as the angle of the lens. To establish the anatomic vertical compartment under the endoscope might be helpful to the operation. The midline vertical compartment consisted of the planum sphenoidale, tubereulum sella, sella and clival indertation. The paramedian vertical compartment was composed of the medial third of the optic canal and the carotid artery protuberance. The lateral vertical compartment contained four bony protuberances（ optic, cavernous sinus apex, maxillary, and mandibular）. Endoscopic surgical maneuvering was under non-midline direction. Precise surgical landmarks are essential for a successful operation. These landmarks allowed the surgeon to recognize and approach the surgical target without confusion. The nasopharynx, middle turbinate, and inferior turbinate were some of the landmarks in the nasal cavity. Once the sphenoidal sinus was entered, the anatomic structures of the sphenoidal sinus posterior wall, which were described above, were the unique landmarks that will guide the surgeon to the surgical target. Conclusion The anatomic characteristics under endoscope were different from those under microscope. The application of the extended transsphenoidal approach under endoscope could provide more extensive vision and satisfied exposure to reach the area of the central skull base.