经鼻入路颅前窝手术安全界限的解剖学研究

Anatomical study on the safety margin of anterior cranial fossa surgery by transnasal approach

目的观测经鼻入路颅前窝手术通道上的重要解剖标志。方法成人干性颅骨标本和经福尔马林液固定的成人尸颅标本各10例,在手术显微镜下观测蝶窦、筛窦、筛前动脉、筛后动脉及视神经等结构及毗邻关系,测量两眼眶内侧壁在鸡冠中部和筛前动脉管、筛后动脉管及视神经管颅口处的宽度。经福尔马林液固定的新鲜成人尸颅标本3例,在新鲜尸颅上模拟手术入路,分析解剖标志与手术通道的关系。结果经鼻入路切除钩突,经筛窦和颅前窝骨质即可进入颅腔。两眼眶内侧壁在鸡冠中部和筛前动脉管、筛后动脉管及视神经管颅口处的宽度分别为(22.3±3.1)mm、(23.0±2.9)mm、(26.2±2.9)mm、(14.7±3.8)mm。结论经鼻入路颅前窝手术是治疗颅前窝病变有价值的选择。术中合理扩展手术通道,控制筛动脉出血,早期确定视神经管和颈内动脉走行,保护纸样板及保持中线操作是手术安全开展的关键。

Objective To observe important anatomical marks in the transnasal approach for anterior cranial fossa surgery.Methods The adult dry skull and formalin-fixed adult cadaveric heads were 10 specimens respectively.The anatomic landmarks and relationship with adjacent structures were observed under microscope,such as the sphenoid sinus,ethmoidal sinus,anterior and posterior ethmoidal arteries,optic canal.The widths between the medial walls of the bilateral orbits were measured respectively at the midportion of the comb and at the cranial end of the anterior ethmoidal arteries,posterior ethmoidal arteries and optic canal.And the surgical approach was simulated on 3 specimens of formalin-fixed fresh adult cadaver heads for analyzing the relationship between anatomic landmarks and surgical approach.Results After the uncinate process was removed via a transnasal approach,cranial cavity was reached passing through the ethmoidal sinus and anterior cranial fossa.The widths between the medial walls of the bilateral orbit at the midportion of the comb and at the cranial ends of anterior ethmoidal arteries,posterior ethmoidal arteries and optic canal were 22.3±3.1 mm,23.0± 2.9 mm,26.2±2.9 mm,and 14.7±3.8 mm respectively.Conclusions The transnasal approach is a valuable option for treatment of anterior cranial fossa lesions.Reasonable expansion of surgical approach,control of ethmoidal arterial bleeding,early location of the optic canal and internal carotid artery,protection of the lamina papyracea,and keeping median line operation are key points for a safe surgery.