耳后发际入路内镜辅助下颌下腺切除术的解剖研究

Endoscope-assisted submandibular sialoadenectomy via retroauricular hairline approach: Anatomical study

目的为耳后发际入路内镜辅助下颌下腺切除术提供解剖学依据,并评价其可行性和安全性。方法新鲜尸体15具(30侧),观测耳后发际区和颌下区的解剖层次及重要结构。新鲜尸体5具(10侧),模拟内镜手术,术后解剖标本,观察有无神经、血管损伤。结果耳后发际区的分离层面在表浅肌肉腱膜系统与颈深筋膜浅层之间。胸锁乳突肌上部浅面,由后上至前下依次为枕小神经、耳大神经、颈外静脉。颌下区的分离层面在颈阔肌深面与下颌下腺鞘膜之间。下颌缘支出腮腺后:①66.7%行于下颌骨下缘之上(7.21±0.50)mm;②23.3%平行下颌骨下缘;③10%行于下颌骨下缘以下(9.43±0.32)mm。在咬肌前下角处,面神经下颌缘支均与面动脉和面静脉交叉,交叉点至下颌角距离分别为(29.86±2.77)mm和(25.71±3.32)mm。舌下神经经茎突舌骨肌和二腹肌后腹深面进入颌下区。舌骨舌肌浅面,自上而下分别是舌神经、下颌下腺导管、舌下神经。10侧模拟手术顺利完成,术中无重要结构损伤,无需中转切口。结论熟悉耳后发际区和颌下区的解剖层次、标志及参数,耳后发际入路内镜辅助下颌下腺切除术安全、可行。

Objective To provide the anatomical basis for the endoscope-assisted submandibular sialoadenectomy via retroauricular hairline approach （EASSRHA） and assess its feasibility and safety. Methods The surgical anatomy of retroauricular hairline region and submandibular region was observed in 15 fresh human cadavers （30 halves）. The submandibular gland resections were performed on 5 human cadavers（10 halves）. After the procedure, the related vascular and neural structures were evaluated. Results Dissection in the retroauricular hairline region should be performed between the superficial musculoaponeurotic system and the investing cervical fascia. On the superficial surface of the upper sternocleidomastoid lied the lesser occipital nerve, the great auricular nerve and the external jugular vein. The submandibular region extended between the deep surface of the platysma and submandibular sheath. The marginal mandibular branch emerging from the inferior border of parotid gland was found（7.21±0.50）mm above the inferior border of the mandible in 66.7%, along the inferior border in 23.3% and （9.43±0.32）mm below the inferior border in 10% of the cases. Near the antero-inferior angle of the masseter muscle, the marginal mandibular branches of the facial nerve crossed over the facial artery and facial vein （29.86±2.77）mm and （25.71±3.32）mm from the mandibular angle , respectively. The hypoglossal nerve passed through the deep surface of the stylohyoid muscle and posterior belly of digastric muscle to enter the submandibular region. On the superficial surface of hyoglossus lied the lingual nerve, the Wharton＇s duct and the hypoglossal nerve. In all cases, the resection of the submandibular gland was successful without the need for an additional incision. No major neurovascular damage was reported. Conclusions A thorough knowledge of the surgical anatomy of the retroauricular hairline region and submandibular region is an essential requirement in performing the safe and feasible submandibular sialoadenectomy.